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You are viewing Clinical Documentation Specialist at Advent Health Clinic or Office-based

Full time

Job Description

  • Demonstrates our mission of extending the healing ministry of Christ, through behavioral whole care standards of loving me, making it easy, owning it, and keeping 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 records for compliance including completeness and accuracy for the severity of illness (SOI), risk of mortality (ROM), and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.
  • Completes accurate and timely record reviews 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 WebEx.
  • 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.
  • Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs to ensure documentation compliance is accomplished.


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