CDE I, RN

Position Summary Department: Clinical Documentation Excellence Shift: Day / Full Time Location: Lakeland, Fl Title: CDE I, RN Position Summary 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.