Clinical Documentation Auditor

AdventHealth

  • Orlando, FL
  • Permanent
  • Full-time
  • 17 days ago
All the benefits and perks you need for you and your family:Benefits from Day OnePaid Days Off from Day OneCareer DevelopmentWhole Person Wellbeing ResourcesMental Health Resources and SupportOur promise to you:Joining AdventHealth is about being part of something bigger. Its about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.Schedule: Full TimeShift: DaysLocation: RemoteThe role youll contribute:The Clinical Documentation Integrity Manager is a Registered Nurse and/or a Registered Health Information Administrator with a high level of clinical proficiency necessary for the oversight of the Clinical Documentation team which is comprised of registered nurses and clinical documentation specialists. This role will oversee the review processes of complex patients that vary in age and have different developments in the acute and chronic disease states. Must have proven leadership and management skills that will promote effective and efficient review of physician documentation that supports the patient's level of care and develop action plans for improvement. Must have knowledge and job experience in management of processes, system implementations, and project management. The Manager of Clinical Documentation works to strategically plan, organize, implement and evaluate the Compliant Documentation Management Program (CDMP) at AdventHealth. This includes management of the case mix index (CMI), length of stay (LOS), severity of illness (SOI) and risk of mortality (ROM) in cooperation with the Director of Clinical Documentation Improvement and all other operational hospital departments. The manager manages the Clinical Documentation Specialists (CDSs) in planning, implementing improvements, and re-evaluating processes to keep staff engaged and to assist in meeting department goals. This role will oversee the review processes of complex patients that vary in age and have different developments in the acute and chronic disease states. Must have proven leadership and management skills that will promote effective and efficient review of physician documentation that supports the patient's level of care and develop action plans for improvement. Must have knowledge and job experience in management of processes, system implementations, and project management. The Clinical Documentation Manager will report directly to the Regional Clinical Documentation Director and will work extensively with CDI teams, physicians, Chief Medical Officers and Chief Nursing Officers of the current 6 hospitals in the North Florida Division in a matrix relationship to coordinate the efficient review and documentation capture of the underlying conditions that are supported by the physicians' secondary review of the patient record, upon request of the clinical documentation team members. Develops, assesses, plans, implements, and evaluates procedures and processes for the system, offers continuing education, process improvement, and change management. Is actively involved in future planning and strategic development for system CDI needs, to include policy development, program development, ongoing audits for the system level and campus level, and quality improvement efforts. Works under general supervision and utilizes critical thinking skills. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.The value youll bring to the team:Reviews concurrent and retrospective medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality.Completes accurate and timely record review to ensure the integrity of documentation compliance.Completes accurate and concise input of data into CDI Software.Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars
  • Conducts audits for quality including, but not limited to deceased second level reviews, focused disease process reviews as needed, patient safety indicators, CDI team audits. Collects data, analyzes data and reports data to CDI Leadership team.
QualificationsThe expertise and experiences youll need to succeed:
  • Work Experience
5 Acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience Required
4 of recent Clinical Documentation Specialist experience Required
1 of Second Level Review CDIS experience Preferred
5 CDI experience Preferred * Additional Licenses and CertificationsCurrent active State license as a Registered Nurse, Nurse Practitioner, Physicians Assistant,
Medical Physician, or an unlicensed Educational Commission for Foreign Medical Graduates
(ECFMG) certified physician who has graduated from a medical school that is listed in the World
Directory of Medical Schools (World Directory) Required
CCDS (Certified Clinical Documentation Specialist) certification or CDIP (Certified
Documentation Improvement Practitioner) certification and 2 years Clinical Documentation
Integrity experience Required This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

AdventHealth