CDE I, RN – Orlando Health – Full -Time Position Available In Orange, Florida

Position SummaryPosition SummaryProvides 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. 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 ResponsibilitiesEducation/TrainingGraduate from an approved school of nursing.

Licensure/CertificationMaintains 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 QualificationsEssential 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 orindividually 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