A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
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. All the benefits and perks you need for you and your family: Benefits from
Day One:
Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance Paid Time Off from Day One 403-B Retirement Plan 4 Weeks 100%
Paid Parental Leave Career Development Whole Person Well-being Resources Mental Health Resources and Support Pet Benefits Schedule:
Full time
Shift:
Day (United States of America)
Address:
2600
LUCIEN WAY City:
MAITLAND
State:
Florida Postal Code:
32751
Job Description:
Reviews clinical documentation and coding during ambulatory encounters to ensure accuracy and completeness. Identifies documentation and coding opportunities, communicates findings to physicians, and conducts timely follow-up reviews. Ensures appropriate clinical documentation is recorded in the patient's chart with accurate ICD-10 coding. Performs concurrent medical record reviews to improve the quality, completeness, and accuracy of documentation. Supports coding compliance, accurate reporting, and improved patient outcomes. Maintains knowledge of coding and billing rules and regulations to ensure documentation supports appropriate reimbursement. Participates in ambulatory and payor coding/documentation compliance activities in accordance with Federal and State regulations. Educates physicians, clinical staff, and other members of the patient care team on documentation guidelines and best practices. Facilitates documentation improvements to accurately capture patient severity of illness and risk factors. Collaborates with physicians, case management staff, nursing staff, patient caregivers, and coding professionals. Assists coding staff in developing and maintaining coding guidelines, policies, and procedures. Submits verbal, electronic, or written queries to clinicians to ensure complete and accurate documentation. Performs other duties as assigned.
Knowledge, Skills, and Abilities:
High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers. [Required] Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge [Required] Regulatory background and risk adjustment/HCC knowledge (Preferred) [Preferred] Experience with CMS and HHS Hierarchical Condition Category coding and auditing [Required]
Education:
Bachelor's [Preferred]
Field of Study:
N/A Work Experience:
2+ experience as a concurrent or retrospective documentation specialist depending on degree [Required] 3+ experience as a concurrent or retrospective documentation specialist. [Required] Clinical experience per licensure/certification requirements listed below [Required] Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, auditing and various healthcare payers (Preferred) [Preferred] Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, auditing and various healthcare payers [Preferred] Strong Ambulatory Background [Preferred]
(Please click the link below to view work requirements) Physical Requirements - https://tinyurl.com/23km2677
Pay Range:
$49,718.59 - $92,468.74 Background Screening Requirement (Florida Law) Certain positions are subject to Florida Level 2 background screening , including fingerprinting, as required by state law. Applicants may review general information about Florida's background screening requirements at the
Florida Care Provider Background Screening Clearinghouse :
https://info.flclearinghouse.com/ This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
