CDE I, RN - Day - Full Time - Bayfront Corp.

Position Summary Department : Clinical Documentation Excellence; Shift : Day/Full Time; Location : Bayfront - NOT in Orlando, FL; this is a Corp role at Orlando Health Bayfront. Address : St. Petersburg, FL 33701; Title : CDE I, RN; Summary : Provides concurrent review of the clinical documentation in the medical record; reviews the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. Note: Promotional language and non-job-related statements have been removed to focus on essential job-related information. Responsibilities Conducts initial and follow-up concurrent reviews across hospitals on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of patient acuity and justification of the level of care. Coordinates with coding, HIM, UR, and other departments to achieve a record that reflects patient acuity and level of care provided. Reviews the medical record concurrently for documentation not yet in the record but supported by clinical indicators; performs thorough chart reviews to identify co-morbidities/complications and documents these appropriately within the concurrent CDS workflow. Determines the appropriate principal diagnosis. Demonstrates an understanding of the importance of capturing all appropriate secondary diagnoses for quality purposes. Documents findings in workflow tools, noting key information used in the tracking process. Uses relationship-building and strong communication skills to develop rapport with providers to 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 supportspatient 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, rounding on units, etc. Reviews the progress of the CDE program by interpreting performance, process, and quality rating reports; identifies areas of focus through report analysis. Maintains productivity levels established by the department. Attends educational sessions and designated meetings as assigned. Maintains regular, punctual attendance in accordance with Orlando Health policies, and applicable laws. Other duties as assigned. Maintains compliance with all Orlando Health policies and procedures. 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) years acute care hospital nursing experience required; extensive clinical knowledge and understanding of pathology/physiology; knowledge of age-specific patient needs and disease processes; excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers. #J-18808-Ljbffr