Registered Nurse (RN) - Med Surg
Orlando Health
Orlando, FL

CDE I, RN - Orlando Health Southlake Hospital

Position Summary Orlando Health - Southlake Hospital Department: Clinical Documentation Excellence - Corp Status: Variable Full Time Shift: varies Title: RN Clinical Documentation Excellence Specialist I Summary: Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. Location: OH Southlake Hospital Forbes has named Orlando Health as one of America's Best-In-State Employers. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions. "Orlando Health Is Your Best Place to Work" is not just something we say, it's our promise to you. ORLANDO HEALTH - BENEFITS & PERKS: Competitive Pay Evening, nights, and weekend shift differentials offered for qualifying positions. All Inclusive Benefits (start day one) Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees. Forbes Recognizes Orlando Health as a Best-In-State Employer Forbes has named Orlando Health as one of America's Best-In-State Employers for 2021. Orlando Health is the top healthcare organization in the Metro Orlando area to make the prestigious list. "We are proud to be named once again as a best place to work," said Karen Frenier, VP (HR). "This achievement reflects our positive culture and efforts to ensure that all team members feel respected, supported and valued. Employee-centric Orlando Health has been selected as one of the "Best Places to Work in Healthcare" by Modern Healthcare. Responsibilities Essential Functions • Conducts initial and follow-up concurrent reviews across all hospitals on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care. • Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided. • Reviews medical record concurrently for documentation not yet in the record but supported by clinical indicators. Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet. Determines the appropriate principal diagnosis of the patient. • Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality purposes. • Documentsfindingsin workflow tools, noting all key information used in the tracking process. • Uses relationship building and strong communication skills to develop a rapport with providersto clarify information in the medical record. • Uses appropriate clarification tools(templates) to capture needed documentation. • Submits clarifications to the medical staff, when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Provides education to providers, clinicians on the importance of complete documentation and key documentation concepts during regular provider meetings or individually with providers, clinicians, rounding on units, etc. • Reviewsthe progress of the CDE program by interpreting performance, process, and quality ratingsreports. Able to identify areas of focus through report analysis. • Maintains levels of productivity established by department. • Attends other educational sessions and designated meetings as assigned. • Maintainsreasonably regular, punctual attendance consistent withOrlando Health policies, the ADA, FMLA, and otherfederal, state, and local standards. • Other duties as assigned. • Maintains compliance with all Orlando Health policies and procedures. Other Related Functions • Performsroutine assignments using existing procedures. • Maintains established work production standards. • Develops competence by performing structured work assignments. • Through training, displays conceptual knowledge of theories, practices and proceduresrelated to CDE. • Assumesthe responsibility for professional growth and development. • Ability to work independently in a time-oriented environment. • Receivesinstruction, guidance, and direction from others. • Maintains 100% compliance with all required employee education. Qualifications Education/Training Graduate from an approved school of nursing. Licensure/Certification Maintains current State of Florida RN license or valid eNLC multistate RN license. Experience Three (3) year acute care hospital nursing experience required. Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Knowledge of age-specific patient needs and the elements of disease processes and related procedures. Excellent written and verbal communication skills; ability towrite concisely and effectively when communicating with providers. Education/Training Graduate from an approved school of nursing. Licensure/Certification Maintains current State of Florida RN license or valid eNLC multistate RN license. Experience Three (3) year acute care hospital nursing experience required. Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Knowledge of age-specific patient needs and the elements of disease processes and related procedures. Excellent written and verbal communication skills; ability towrite concisely and effectively when communicating with providers. Essential Functions • Conducts initial and follow-up concurrent reviews across all hospitals on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care. • Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided. • Reviews medical record concurrently for documentation not yet in the record but supported by clinical indicators. Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet. Determines the appropriate principal diagnosis of the patient. • Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality purposes. • Documentsfindingsin workflow tools, noting all key information used in the tracking process. • Uses relationship building and strong communication skills to develop a rapport with providersto clarify information in the medical record. • Uses appropriate clarification tools(templates) to capture needed documentation. • Submits clarifications to the medical staff, when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Provides education to providers, clinicians on the importance of complete documentation and key documentation concepts during regular provider meetings or individually with providers, clinicians, rounding on units, etc. • Reviewsthe progress of the CDE program by interpreting performance, process, and quality ratingsreports. Able to identify areas of focus through report analysis. • Maintains levels of productivity established by department. • Attends other educational sessions and designated meetings as assigned. • Maintainsreasonably regular, punctual attendance consistent withOrlando Health policies, the ADA, FMLA, and otherfederal, state, and local standards. • Other duties as assigned. • Maintains compliance with all Orlando Health policies and procedures. Other Related Functions • Performsroutine assignments using existing procedures. • Maintains established work production standards. • Develops competence by performing structured work assignments. • Through training, displays conceptual knowledge of theories, practices and proceduresrelated to CDE. • Assumesthe responsibility for professional growth and development. • Ability to work independently in a time-oriented environment. • Receivesinstruction, guidance, and direction from others. • Maintains 100% compliance with all required employee education.