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

Position Summary Department: Clinical Documentation Excellence Shift: Day/Full Time Location: Orlando Health Bayfront Title: CDE I, RN 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. Employer Overview “Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you. Orlando Health proudly embraces and honors the individuality of our team members. By sharing different ideas and perspectives and working together as a team, we are better able to relate to, care for and authentically serve our patients and families who make up the collective populations in our community. So, no matter who you are, what you believe or how you express yourself, you are welcome here. 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, backup 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 Conduct 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. Coordinate with coding, HIM, UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided. Review medical record concurrently for documentation not yet in the record but supported by clinical indicators. Perform a thorough chart review to identify co‑morbidities/complications, and document these appropriately within the concurrent CDS worksheet; determine the appropriate principal diagnosis of the patient. Demonstrate an understanding of the importance of, and make an effort to capture, all appropriate secondary diagnoses for quality purposes. Document findings in workflow tools, noting all key information used in the tracking process. Use relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record. Use appropriate clarification tools (templates) to capture needed documentation. Submit 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. Provide 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. Review the progress of the CDE program by interpreting performance, process, and quality ratings reports; identify areas of focus through report analysis. Maintain levels of productivity established by department. Attend other educational sessions and designated meetings as assigned. Maintain reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, local standards. Other duties as assigned. Maintain compliance with all Orlando Health policies and procedures. Other Related Functions Perform routine assignments using existing procedures. Maintain established work production standards. Develop competence by performing structured work assignments. Through training, display conceptual knowledge of theories, practices and procedures related to CDE. Assume responsibility for professional growth and development. Ability to work independently in a time‑oriented environment. Receive instruction, guidance, and direction from others. Maintain 100% compliance with all required employee education. Qualifications Education/Training Graduate from an approved school of nursing. Licensure/Certification Maintain 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 to write concisely and effectively when communicating with providers. #J-18808-Ljbffr