Registered Nurse (RN) - Clinical Document Improvement Specialist
Orlando Health
Orlando, FL

CDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer Hospital

Position 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. This is a hybrid position, hospital will be Arnold Palmer Childrens Hospital 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) year acute care hospital experience required. * Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Responsibilities Conducts initial and follow-up concurrent reviews 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. * Review 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 principle diagnosis of the patient. * Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes. * 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 to clarify information in the medical record. * Uses appropriate querying tools (templates) to capture needed documentation. * Queries 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 physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians. * Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Able to identify areas of focus through report analysis. * Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards. * Maintains compliance with all Orlando Health policies and procedures. 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) year acute care hospital experience required. * Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Conducts initial and follow-up concurrent reviews 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. * Review 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 principle diagnosis of the patient. * Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes. * 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 to clarify information in the medical record. * Uses appropriate querying tools (templates) to capture needed documentation. * Queries 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 physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians. * Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Able to identify areas of focus through report analysis. * Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards. * Maintains compliance with all Orlando Health policies and procedures.