Clinical Documentation Quality Liaison

Description

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

• Student Loan Repayment Program
• Nursing Clinical Ladder Program
• Whole Person Wellbeing Resources
• Benefits from Day One
• Paid Days Off from Day One
• Team Based Nursing Model

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: Full Time

Shift: Days

Location: Remote

The role you’ll contribute:

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 Quality Auditor Manager strategically facilitates and obtain 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. The Clinical Documentation Quality Auditor Manager educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, care management and quality abstracters. The Clinical Documentation Quality Auditor Manager adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you’ll bring to the team:

• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
• Participates in Task Force meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group.
• Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications
• Demonstrates, through behavior, Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork
• Reviews mortality reviews and quality audits to ensure the ROI/SOM scores are appropriate and consistent in documentation of care delivered. Quality audits consist of but not limited to concurrent, mortality, Iodine Retrospect and other internal CDI audits to ensure compliance to guidelines.
• Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into Iodine resulting in accurate metrics provided by the Iodine metrics. Understands and supports documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx’s.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance. Initiates/formulates Iodine severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management. This includes quarterly compliance updates from Medicare.

Qualifications

Minimum qualifications:

• BSN (MSN preferred)
• 2 years Clinical Documentation Specialist experience
• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• Certified Clinical Documentation Specialist (CCDS)
• Current active State license as a Registered Nurse, Nurse Practitioner, or Physician’s Assistant

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