Clinical Documentation Excellence I, RN - Full Time - Lakeland

CDE I, RN

Conducts initial and follow-up concurrent reviews across multiple hospitals on targeted admissions for opportunities to clarify and/or validate documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.

Essential Functions:

• 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 records for documentation not yet in the record but supported by clinical indicators. Performs a thorough chart review to determine the appropriate principal diagnosis and to identify and/or validate co-morbidities/complications, documenting these appropriately within the current CDS software tool.
• Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate diagnoses for an accurate and complete medical record.
• Documents findings in workflow tools, noting all key information used in the tracking process.
• Uses relationship building and strong communication skills to develop a rapport with providers, physician advisors, and key stakeholders to clarify information in the medical record.
• Uses appropriate clarification tools (templates) to capture needed documentation.
• Submits clarifications to providers, 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.
• Reviews the progress of the CDE program by interpreting performance, process, and quality ratings reports. Able to identify areas of focus through report analysis updates.
• Maintains levels of productivity established by department.
• Attends other educational sessions and designated meetings as assigned.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
• Other duties as assigned.
• Maintains compliance with all Orlando Health policies and procedures.

Other Related Functions:

• Performs routine 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 procedures related to CDE.
• Assumes the responsibility for professional growth and development.
• Ability to work independently in a time-oriented environment.
• Receives instruction, moderate level of guidance, and direction from others.
• Demonstrates consistent growth and knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG and APR-DRG.
• Maintains 100% compliance with all required employee education.
• Excellent written and verbal communication skills; ability to write 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) years acute care hospital nursing experience required.