Senior Clinical Documentation Improvement Specialist

Senior Clinical Documentation Improvement Specialist-Ambulatory

All the benefits and perks you need for you and your family:

• Benefits from Day One
• Paid Time Off from Day One
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support

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.

Schedule: Monday-Friday

Shift: 8:00 am - 5:00 pm

Location : 2600 Lucien Way, Maitland (Hybrid), Must live in the central Florida region

The community you'll be caring for:

• Join a team that provides exceptional patient-based care.
• Collaborative teams that work together for a common goal
• Compassionate and supportive leaders ensure work life balance for team members and providers without compromising patient care.

The role you'll contribute:

The Specialist Ambulatory CDI Senior demonstrates strong clinical knowledge and understanding of coding/Hierarchical Condition Categories (HCC)/Risk Adjustment Factor (RAF) requirements and Clinical Care Gaps to improve overall quality and completeness of clinical documentation in the patient medical record on a concurrent, and potentially a prospective and retrospective basis, using a multi-disciplinary team process. The Specialist Ambulatory CDI Senior works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement and risk adjustment factors scores. This position is responsible for understanding the clinical Care Gaps for different populations, using physicians' education and multi-disciplinary team approach to help closing them.

The value you'll bring to the team:

• Reviews clinical documentation and coding during ambulatory encounters and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart and appropriate ICD-10 codes are attached to the visit.
• Performs concurrent medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate risk scoring, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned.
• Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement.
• Participates in assuring ambulatory and payor coding/documentation compliance with Federal and State regulatory bodies.

Qualifications
Minimum qualifications

• High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers.
• Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge
• Clinical experience per licensure/certification requirements listed below
• At least two (2) years of experience as a concurrent or retrospective documentation specialist depending on degree
• CDIP, CCDS or CPC (Clinical Documentation Improvement Practitioner/Certified Clinical Documentation Specialist/Certified Professional Coder) AND EITHER
• Three (3) years of experience as a concurrent or retrospective documentation specialist.

Preferred experience:

• Regulatory background and risk adjustment/HCC knowledge (Preferred)

---