Clinical Documentation Integrity Specialist II

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: 9100 W 74TH ST City: SHAWNEE MISSION State: Kansas Postal Code: 66204 Job Description:

Clinical Document Specialist II – Full-Time Location: Remote- role is fully Remote-must be licensed in KS Schedule: Full-Time | Day Shift Required: Kansas Nursing License or current Multi-State Nursing License

Job Summary Responsible for facilitating and obtaining accurate, complete, and compliant physician documentation to support the severity of illness, risk of mortality, quality outcomes, and complexity of Obstetrics and NICU patient care. Educates physicians, advanced practice providers, nursing staff, care management, and other healthcare professionals regarding documentation standards, regulatory requirements, and clinical documentation improvement (CDI) practices. Ensures adherence to organizational policies, regulatory guidelines, departmental goals, and performance standards while promoting documentation integrity and compliance. Contributes to the efficiency and effectiveness of clinical documentation processes through collaboration, critical thinking, and continuous improvement efforts.

Essential Functions

• Facilitates clinical documentation improvement activities to ensure accurate representation of patient acuity, severity of illness, risk of mortality, and quality outcomes.

• Reviews concurrent medical records for completeness, accuracy, compliance, and documentation opportunities.

• Identifies opportunities for documentation improvement through analysis of clinical indicators, medical necessity, and patient care documentation.

• Develops and communicates clinically supported documentation clarifications to physicians, advanced practice providers, and other members of the healthcare team.

• Initiates and formulates CDI severity worksheets and documentation queries that support compliant documentation practices.

• Reviews and reconciles documentation related to severity of illness (SOI), risk of mortality (ROM), patient safety indicators (PSI), hospital-acquired conditions (HAC), hierarchical condition categories (HCC), and other quality measures.

• Accurately enters and maintains CDI data within designated software systems, supporting reporting and performance metrics.

• Collaborates with physicians, nursing staff, HIM professionals, coders, and other healthcare team members to improve documentation quality and accuracy.

• Works with Health Information Management staff to resolve DRG assignment discrepancies and coding-related documentation issues.

• Conducts timely follow-up reviews on concurrent cases and prioritizes cases requiring clarification resolution.

• Educates physicians, advanced practice providers, nursing staff, and other healthcare professionals regarding documentation requirements, regulatory guidelines, and best practices.

• Maintains physician engagement and supports timely responses to documentation clarification requests.

• Participates in departmental meetings, educational initiatives, performance improvement activities, and process improvement efforts.

• Assists with orientation, training, mentoring, and precepting of new team members.

• Completes annual educational projects and presentations for the CDI team.

• Maintains documentation integrity and compliance with organizational, regulatory, and accreditation requirements.

• Performs other duties as assigned.

Knowledge, Skills, and Abilities

• Excellent verbal and written communication skills with the ability to develop and maintain effective professional relationships.

• Demonstrated ability to communicate effectively with physicians, advanced practice providers, and interdisciplinary healthcare teams.

• Strong organizational, prioritization, and time management skills.

• Ability to manage multiple responsibilities and competing priorities in a fast-paced healthcare environment.

• Proficiency in computer applications, electronic health record systems, CDI software, and related technologies.

• Ability to work effectively with multiple software applications simultaneously.

• Strong critical thinking, clinical reasoning, problem-solving, and decision-making skills.

• Ability to analyze clinical documentation and identify opportunities for improvement.

• Knowledge of pathophysiology, disease processes, clinical treatment modalities, and patient care practices.

• Knowledge of clinical documentation improvement principles and documentation requirements.

• Knowledge of coding concepts, DRG methodology, reimbursement systems, and healthcare quality measures.

• Knowledge of regulatory, compliance, accreditation, and quality reporting requirements.

• Ability to organize, interpret, and present information clearly and concisely.

• Demonstrated ability to learn, develop, and refine clinical documentation improvement skills.

• Dependable, self-motivated, professional, and collaborative.

• Ability to work independently while maintaining strong teamwork and customer service standards.

Education

• RN/Associate's Degree required.

• BSN Preferred

Field of Study

• Nursing or a health-related field.

Work Experience

• 5 years of Clinical Documentation Integrity (CDI) experience involving Obstetric and/or Neonatal Intensive Care Unit (NICU) patient populations, including review of Obstetric and NICU cases.

• Acute care nursing experience in Obstetrics, Labor & Delivery, Mother-Baby, Women's Services, NICU, or related specialties strongly preferred.

• Five years of Clinical Documentation Improvement (CDI) experience required.

Required Education

• Current and active Registered Nurse (RN)

• Certified Clinical Documentation Specialist (CCDS) required.

• JATA training preferred.

•

Physical Requirements: (Please click the link below to view work requirements)

Physical Requirements - https://tinyurl.com/23km2677

Pay Range:

$67,662.40 - $125,860.80 This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.