Clinical Documentation Integrity Specialist (Remote) Shift : Full-time; Monday‑Friday Job Location : Remote The Role You Will Contribute Under general supervision of the Director of Clinical Documentation Integrity and, in some situations, 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. The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management, and adheres to strict departmental and organizational goals, objectives, standards, and policies. The CDS actively participates in outstanding customer service, maintains respectful relationships, and ensures consistent, high‑quality documentation and regulatory compliance. Responsibilities Demonstrate extending the healing ministry of Christ, delivering exceptional care, and striving for excellence. Review concurrent medical records for documentation compliance, ensuring completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality. Complete accurate and timely record review to maintain documentation integrity and enter data into CDI software for accurate metrics. Recognize opportunities for documentation improvement using strong critical‑thinking skills and formulate CDI severity worksheets and clinically credible clarifications for inpatient documentation. Transcribe documentation clarifications for SOI, ROM, PSI, HCCs, and HACs to ensure compliance. Educate the patient‑care team on documentation regulations and guidelines, including annual compliance updates from Medicare. Effectively communicate with physicians and other healthcare providers to ensure accurate and complete clinical documentation; collaborate with HIM staff to resolve DRG assignment and coding discrepancies. Complete well‑timed follow‑up case reviews on all cases, prioritizing resolution of documentation clarifications. Participate in departmental meetings, provide feedback on outstanding issues, deliver educational presentations, and address needs identified by CDI leaders. Assume personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency. Formulate clear clarifications for physicians and other medical team members. Accurately reconcile all cases in CDI software. Assist in new hire orientation through precepting and mentoring. Maintain CCDS credentialing. The Expertise and Experiences You'll Need to Succeed Associate degree and 5 years of experience 5 years acute care experience 2 years CDI experience Licensure, Certification or Registration Required Current active State license as a Registered Nurse, Nurse Practitioner, Physician's Assistant, or an unlicensed physician who has graduated from a medical school listed in the World Directory of Medical Schools and meets ECFMG eligibility. CCDS (Certified Clinical Documentation Specialist) certification, and/or CDIP (Certified Documentation Improvement Practitioner) certification. Preferred Qualifications BSN or higher degree and 3 years of CDI experience CCS (Certified Coding Specialist) This facility is an equal opportunity employer and complies with federal, state and local anti‑discrimination laws, regulations and ordinances. We do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap. All employees are equally included in recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment. Altamonte Springs, FL. Benefits Benefits from Day One Career Development Whole Person Wellbeing Resources Mental Health Resources and Support Industry Hospitals and Health Care #J-18808-Ljbffr AdventHealth
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