Department Clinical Documentation Excellence Shift: Day/Full Time
Location: Orlando Health Bayfront
Title: CDE I, RN
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.
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Orlando Health proudly embraces and honors the individuality of our team members. By sharing different ideas and perspectives and working together as a team, we are better able to relate to, care for and authentically serve our patients and families who make up the collective populations in our community. So, no matter who you are, what you believe or how you express yourself, you are welcome here.
ORLANDO HEALTH - BENEFITS & PERKS:
Competitive Pay
All Inclusive Benefits (start day one)
Forbes Recognizes Orlando Health as a Best-In-State Employer
Employee-centric
Orlando Health has been selected as one of the “Best Places to Work in Healthcare” by Modern Healthcare.
Essential 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.Other Related Functions• Performsroutine 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 proceduresrelated to CDE.• Assumesthe responsibility for professional growth and development.• Ability to work independently in a time-oriented environment.• Receivesinstruction, guidance, and direction from others.• Maintains 100% compliance with all required employee education.
Education/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
Situated in the heart of downtown St. Petersburg, Florida, Orlando Health Bayfront Hospital has served the residents of area communities for more than 110 years. Orlando Health, a not-for-profit healthcare organization headquartered in Central Florida, officially acquired Bayfront Hospital on October 1, 2020. Orlando Health Bayfront Hospital is a 480-bed comprehensive emergency, medical and surgical acute care facility – and home to the only state-accredited Level Two Adult Trauma Center in the St. Petersburg region. As a regional leader in emergency care, our 3 conveniently located emergency rooms are staffed with board-certified physicians and specialty-trained clinical teams who are ready to provide expert emergency care for all ages- 24 hours a day, seven days a week.
With advanced technology and expertise in numerous specialties including heart and vascular, neurosciences, digestive health, maternity care, emergency and trauma care, acute rehabilitation and surgical services, Orlando Health Bayfront Hospital provides a complete continuum of care. The hospital has a 38-bed neurosciences unit with a dedicated neurology team consisting of board-certified neuroscience specialists and physicians with subspecialty expertise in stroke, epilepsy and Parkinson’s disease, and includes a Level IV Epilepsy Center. In partnership with Johns Hopkins All Children’s Hospital, Bayfront Health Baby Place offers full obstetrical services and is a Level III Regional Perinatal Intensive Care Center, one of only 13 in Florida. The Bayfront Health Cardiac Cath Lab, offers more cardiac testing and treatment space than any other provider in the St. Petersburg/Pinellas County area, with ease of access to the cardiac surgical program. The hospital is also home to three residency programs and one fellowship program, providing an exceptional teaching and learning environment to train the healthcare leaders of the future.
