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.

• Bachelor's BSN
• Five plus acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• Three plus of Clinical Documentation Specialist experience

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

AdventHealth Orlando, 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.