Description

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

　　Benefits from Day One

　　Paid Days Off from Day One

　　Student Loan Repayment Program

　　Career Development

　　Pet Insurance

　　Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)

　　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: Day

　　Location: 900 WINDERLEY PL, Maitland, 32751

　　Job Summary:

　　Under general supervision of the Director of Clinical Documentation Integrity, and in collaboration with physicians, nursing and HIM coders, the Documentation Quality Reviewer (DQR) , is responsible for reviewing medical records for quality and core measures. The DQR 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, and to support ICD-10 codes. The DQR collects data, analyzes data and reports data to CDI Director. The DQR educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and care management. The DQR will act as a liaison to the CDI and coding staff. The DQR will serve as a resource to the CDI team, CDI Educator, CDI Managers and CDI Director. The DQR adheres to 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.

　　You Will Be Responsible For:

　　Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.

　　Conducts audits for quality including, but not limited to deceased second level reviews, focused disease process reviews as needed, patient safety indicators, CDI team audits. Collects data, analyzes data and reports data to CDI Director and CDI Leadership team.

　　Completes accurate and timely record review. Recognizes opportunities for documentation improvement.

　　Educates members of the patient-care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and care management.

　　Collaborates with coding and quality team to communicate discrepancies in the capture of patient safety indicators, Hospital acquired infections, Hospital acquired conditions, and core measures.Communicates with HIM staff and resolves discrepancies. Completes accurate input of documentation into CDMP Trak.

　　Effectively and appropriately communicates with physicians.

　　Qualifications

　　What Will You Need:

　　EDUCATION AND EXPERIENCE REQUIRED :

　　Two (2) years of Clinical Documentation Specialist experience

　　Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU

　　LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED :

　　Current valid State of Florida or multi state license as a Registered NurseEDUCATION AND EXPERIENCE PREFERRED :

　　Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU

　　BSN or MSN

　　LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED :

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

　　Category: Health Information Management

　　Organization: AdventHealth Orlando

　　Schedule: Full-time

　　Shift: 1 - Day

　　Req ID: 24002864

　　We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.