Registered Nurse Clinical Documentation Specialist AdventHealth Tampa
Location Address: 3100 East Fletcher Avenue Tampa, Florida 33613
Top Reasons to Work at AdventHealth Tampa
- Florida Hospital Pepin Heart Institute, known across the country for its advances in cardiovascular disease prevention, diagnosis, treatment and research.
- Surgical Pioneers – the first in Tampa with the latest robotics in spine surgery
- Building a brand new, six story surgical and patient care tower which will ensure state of the art medical and surgical car for generations to come
- Awarded the Get With The Guidelines – Stroke GOLD Quality Achievement Award from the American Heart Association/American Stroke Association and have been recognized as a recipient of their Target: Stroke Honor Roll for our expertise in stroke care. We have also received certification by The Joint Commission in collaboration with the American Stroke Association as a Primary Stroke Center.
Full Time Days
You Will Be Responsible For:
- Demonstrates, through behavior, Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork
- Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.
- Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDMP Trak resulting in accurate metrics provided by the CDMP program. Understands and supports CDMP documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx’s.
- Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance. Initiates/formulates CDMP severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff.
- Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
What You Will Need:
- Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations.
- Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills.
- Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist
- Dependable, self-motivated and pleasant
- Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills
- Knowledge of pathophysiology, disease processes and treatments
- Knowledge of regulatory environment
- Strong ability to organize/triage work and manage multiple priorities at once
- Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
- Current active State license as a Registered Nurse, Nurse Practitioner, or Physician’s Assistant
- Adventist Health Care online learning
- Achieve a 70% or greater on JA Thomas Clinical Competency Pre-Assessment.
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 obtain 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 attending 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.