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Clinical Document Specialist III

Clinical Document Specialist III

at AdventHealth

Posted: 3-11-2025

Remote

Healthcare

Ï

$104,083/year

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About this Career

Medical Records Specialists

Skills

Customer Service, Nurse Practitioner (APRN-CNP), Acute Care Nursing, Medical Records, Case Management, Intensive Care Unit, Certified Documentation Improvement Practitioner (CDIP), Care Management, Nursing, Clinical Documentation Integrity (CDI), Decision Making, Critical Thinking, Emergency Departments, Reconciliation, Regulatory Compliance, Medical Surgical Nursing, Registered Nurse (RN), Clinical Documentation, Certified Clinical Documentation Specialist (CCDS)

Job Description

Clinical Document Specialist III Orlando, FL AdventHealth Orlando
Job Schedule:
Full-time
Pay Range:
$40.78 - $61.17 per hour
Job ID:
25008794
Job Family:
Case Management
Shift:
1 - Day Facilities Benefits Hiring Process At AdventHealth Orlando, what started as a converted farmhouse in rural Central Florida has become Central Florida's major tertiary health care facility. Patients come from the Southeast, the Caribbean and even as far as South America for our proven expertise and compassionate health care. With a variety of Orlando hospital jobs, we invite you to start or elevate your career with a new job at AdventHealth Orlando. We constantly seek out Orlando nurses, medical assistants, nurse assistants, patient care and health administration professionals who share our passion for whole-person health care. Learn more about our open positions and apply to become an invaluable part of our team. Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we're committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier. All the benefits and perks you need for you and your family:
  • Benefits from Day One
  • Paid Days Off from Day One
  • Debt-free Education
  • (Certifications and Degrees without out-of-pocket tuition expense) for eligible positions Joining AdventHealth is about being part of something bigger.
It's 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:
Monday to Friday, 40 hrs - Fully Remote - Flexible hours may be between 6a-630pm
Shift:
Full Time Days Salary Exempt The community you'll be caring for:
  • Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando
  • We offer great benefits with immediate Health Insurance coverage
  • Career growth and advancement potential
  • Serves as the major tertiary facility for much of the Southeast, the Caribbean and South America
  • AdventHealth Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country
  • We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year The role you'll contribute: Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Specialist (CDS) strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.
The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management. The CDS adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. The value you'll bring to the team: Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of love me, make it easy, own it and keep me safe to every person they meet. Delivers exceptional care and strives for excellence. Committed to improving the health, prosperity and well-being of the communities we serve. Uphold the highest standards, with integrity driving every decision made and every action taken. Guided by relentless stewardship in the management of resources entrusted to them. Reviews concurrent medical record for 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 resulting in accurate metrics obtained through the reconciliation process. 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. Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance. Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other clinical team members. Qualifications The expertise and experiences you'll need to succeed: : Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. BSN and three years of Clinical Documentation Specialist experience Current active State license as a Registered Nurse, Nurse Practitioner, Physician's Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation. CCDS (Certified Clinical Documentation Specialist) certification, in lieu of BSN and 3 years of experience or CDIP (Certified Documentation Improvement Practitioner) certification, in lieu of BSN and 3 years of experience This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
Category:
Case Management
Organization:
AdventHealth Orlando
Schedule:
Full-time
Shift:
1 - Day
Req ID:
25008794 We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment. Internal Employees Apply Here Our promise to you: Joining AdventHealth is about being part of something bigger. It's 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.

Other Job Posting Details

Salary

Minimum

Maximum

$72,779/yr

$135,387/yr

MINIMUM EDUCATION LEVEL

No Education Listed

MINIMUM YEARS EXPERIENCE

5