Clinical Document Spec III

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 (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 Webinars.

• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• BSN and 3 years of Clinical Documentation Specialist experience
• RN - Registered Nurse - State Licensure and/or Compact State Licensure
• NP - Nurse Practitioner
• Licensed
• CCDS - Certified Cardiac Device Specialist in lieu of BSN
• CDIP - Clinical Documentation Improvement Professional in lieu of BSN

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

At AdventHealth, what started as a converted farmhouse in rural Central Florida has become Central Florida’s major tertiary health care facility. Patients come from the Southeast, the Caribbean and even as far as South America for our proven expertise and compassionate health care.