Clinical Document Spec II

Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of 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 to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.

• Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality.
• Completes accurate and timely record review 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.

• Bachelor's BSN
• 5 years of acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• 3 years of Clinical Documentation Specialist experience
• RN - Registered Nurse - State Licensure and/or Compact State Licensure
• NPC - Certified Nurse Practitioner
• PA - Physician Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation.
• CDIP - Clinical Documentation Improvement Professional CDIP (Certified Documentation Improvement Practitioner) certification, in lieu of BSN and 3 years of experience
• CDS (Certified Clinical Documentation Specialist) certification, in lieu of BSN and 3 years of experience

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

At AdventHealth Winter Garden, which is one of the newest AdventHealth facilities in Central Florida, we’re dedicated to providing exceptional care. And to us, that means expanding our footprint and bringing specialty services close to home and 400 new jobs to the area.