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.

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.

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.