Registered Nurse - Clinical Documentation Quality Liaison - Full Time Days West Florida Division

Registered Nurse Clinical Documentation Quality Liaison

AdventHealth Tampa

Location Address: 3100 East Fletcher Avenue Tampa, Florida 33613

Top Reasons to Work at AdventHealth Tampa

Florida Hospital Pepin Heart Institute, known across the country for its advances in cardiovascular disease prevention, diagnosis, treatment and research.

Surgical Pioneers â“ the first in Tampa with the latest robotics in spine surgery

Building a brand new, six story surgical and patient care tower which will ensure state of the art medical and surgical car for generations to come

Awarded the Get With The Guidelines â“ Stroke GOLD Quality Achievement Award from the American Heart Association/American Stroke Association and have been recognized as a recipient of their Target: Stroke Honor Roll for our expertise in stroke care. We have also received certification by The Joint Commission in collaboration with the American Stroke Association as a Primary Stroke Center.

Work Hours/Shift:

Full Time/ Days

You Will Be Responsible For:

Demonstrates, through behavior, Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork

Reviews mortality reviews to ensure the ROI/SOM scores are appropriate and consistent in documentation of care delivered.   

Completes accurate and timely record review to ensure the integrity of documentation compliance.  Completes accurate and concise input of data into CDMP Trak resulting in accurate metrics provided by the CDMP program.  Understands and supports CDMP documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebExâ™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 CDMP severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff.

Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.

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.

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.

Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications

Participates in Task Force meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group.

Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.

Performs other duties as assigned.

What You Will Need:

     KNOWLEDGE AND SKILLS REQUIRED:

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations.
• Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills.
• High level of expertise as a Clinical Documentation Specialist
• Dependable, self-motivated and pleasant
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills
• Knowledge of pathophysiology, disease processes and treatments
• Knowledge of regulatory environment
• Strong ability to organize/triage work and manage multiple priorities at once

KNOWLEDGE AND SKILLS PREFERRED:

• Knowledge of clinical documentation requirements that identify clinical conditions or procedures. 
• Coding background

EDUCATION AND EXPERIENCE REQUIRED:

• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• BSN (MSN preferred)
• 3-5 years Clinical Documentation Specialist experience

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

• Current active State license as a Registered Nurse, Nurse Practitioner, or Physicianâ™s Assistant

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

• Certified Clinical Documentation Specialist (CCDS) and/or Certified Documentation Improvement Practitoner (CDIP).

REQUIRED COMPETENCIES

• Adventist Health Care online learning
• Achieve a 70% or greater on JA Thomas Clinical Competency Pre-Assessment.
• Achieve a 70% or greater on the JA Thomas Annual Competency

Job Summary:

• 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.