CDI SPECIALIST III REGISTERED NURSE
3 weeks ago
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.
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.
Must maintain current one of the following:
Certified Documentation Specialist (CCDS) by the Association of Clinical Documentation Improvement Specialists
Clinical Documentation Improvement Professional (CDIP) by The American Health Information Management Association
Certified Professional Coder (CPC) by the American Academy of Professional Coders (AAPC)
Certified Coding Specialist (CCS)
Experience
* Three (3) years of acute care hospital experience required.
* Two (2) years of acute care CDI experience required.
* Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital
setting.
* Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG required.
* Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers
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.
* Acts as liaison between the Coding Department and the Clinical Documentation Specialist.
* Regularly interacts with/educates physicians to enhance understanding of the CDI program and to ensure the medical record
can be coded accurately in order to reflect patient severity of illness and risk of mortality.
* Able to recognize and facilitate performance improvement activities when necessary to achieve benchmark departmental and
system metrics.
* 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.
Must maintain current one of the following:
Certified Documentation Specialist (CCDS) by the Association of Clinical Documentation Improvement Specialists
Clinical Documentation Improvement Professional (CDIP) by The American Health Information Management Association
Certified Professional Coder (CPC) by the American Academy of Professional Coders (AAPC)
Certified Coding Specialist (CCS)
Experience
* Three (3) years of acute care hospital experience required.
* Two (2) years of acute care CDI experience required.
* Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital
setting.
* Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG required.
* Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers
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.
* Acts as liaison between the Coding Department and the Clinical Documentation Specialist.
* Regularly interacts with/educates physicians to enhance understanding of the CDI program and to ensure the medical record
can be coded accurately in order to reflect patient severity of illness and risk of mortality.
* Able to recognize and facilitate performance improvement activities when necessary to achieve benchmark departmental and
system metrics.
* 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.
-
CDI Specialist III Registered Nurse
1 month ago
Orlando, United States Orlando Health Full timeCDI Specialist III Registered Nurse - Clinical Documentation - Orlando HealthPosition 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 role Responsibilities Conducts initial and follow-up...
-
CDI Specialist III Registered Nurse
1 month ago
Orlando, FL, United States Orlando Health Full timeCDI Specialist III Registered Nurse - Clinical Documentation - Orlando HealthPosition 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 role Responsibilities Conducts initial and follow-up...
-
CDI Specialist III Registered Nurse
5 days ago
Orlando, FL, United States Orlando Health Full timePosition 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. Qualifications Education/Training Graduate from an approved school of nursing. Licensure/Certification Maintains current State of Florida RN...
-
REGISTERED NURSE
3 weeks ago
Syracuse, NY 13201, USA, United States Crouse Hospital Full timeThe Clinical Documentation Improvement Specialists (CDIS) report to the Director of Health Information Management.# The CDS is responsible for reviewing medical records to facilitate the accurate representation of severity of illness.# This involves extensive record review, interaction with physicians, HIM professionals and nursing staff.# Active...
-
CDI Specialist I Registered Nurse
4 weeks ago
Orlando, FL, United States Orlando Health Full timeCDI 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...
-
CDI Specialist I Registered Nurse
4 weeks ago
Orlando, United States Orlando Health Full timeCDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition 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...
-
CDI Specialist I Registered Nurse
1 week ago
Orlando, FL, United States Orlando Health Full timeCDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition 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...
-
CDI Specialist I Registered Nurse
4 weeks ago
Orlando, FL, United States Orlando Health Full timeCDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition 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...
-
CDI RN SPECIALIST
3 weeks ago
Washington, DC 20319, USA, United States Children's National Medical Center Full timeThe CDI RN Specialist will ensure overall quality and completeness of clinical documentation for specified populations. Will facilitate modifications to clinical documentation through concurrent interaction with physicians and other members of the healthcare team to support (1) the appropriate severity of illness, (2) expected risk of mortality, and (3)...
-
CLINICAL DOCUMENTATION IMPROVEMENT
2 weeks ago
Brooklyn, NY 11210, USA, United States SUNY Downstate Medical Center Full timeThe Department of Health Information Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review and Quality Assurance Senior Coordinator / Clinical Documentation Improvement (CDI) Specialist. Reporting to the Clinical, Specialist, Improvement, Improvement, Leadership, Medical, Healthcare, Education
-
CDI RN SPECIALIST
1 week ago
Roseburg, OR 97470, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CDI RN SPECIALIST
1 month ago
Omaha, NE 68102, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CDI RN SPECIALIST
3 weeks ago
Bismarck, ND 58502, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CDI RN SPECIALIST
6 days ago
Council Bluffs, IA 51501, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CDI RN
2 weeks ago
Spring, TX 77380, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
REGISTERED NURSE
6 days ago
Orlando, FL 32801, USA, United States Orlando Health Full timePosition Summary The RN Advanced Care administers patient care in an area in a hospital or inpatient setting where patients have an advanced illness or injury that routinely requires timely, intense, and complex care to stabilize and support the patient's medical condition. These areas require a lower caregiver-to-patient ratio and highly trained team...
-
Registered Nurse Specialist I
2 days ago
Orlando, FL, United States University of Central Florida Full timeRegistered Nurse Specialist I (TEMP) The Opportunity: The UCF Student Health Team is seeking qualified candidates for a Registered Nurse Specialist I position. The Registered Nurse Specialist I will provide professional culturally competent nursing care to patients. The Registered Nurse Specialist I will practice under the oversight of a licensed healthcare...
-
REGISTERED NURSE SPECIALIST
3 weeks ago
Gainesville, FL 32635, USA, United States State of Florida Full timeThis is a Registered Nurse Specialist position which is responsible for the supervision and coordination of all nursing services to an assigned group of people in a facility for the developmentally disabled. This position is responsible for the coord Registered Nurse, Specialist, Registered, Nurse, Staff, Nursing, Healthcare
-
REGISTERED NURSE SPECIALIST
3 weeks ago
Fort Myers, FL, USA, United States State of Florida Full timeRequisition No: 827770 Agency: Children and Families Working Title: REGISTERED NURSE SPECIALIST - 60057238 Pay Plan: Career Service Position Number: 60057238 Salary: $53,566.50 Posting Closing Date: 05/03/2024 Total Compensation Estimator Tool Regist Registered Nurse, Specialist, Registered, Nurse, Medical, Benefits, Healthcare
-
68061416 - REGISTERED NURSE SPECIALIST SURVEYOR
2 weeks ago
Miami, FL 33222, USA, United States State of Florida Full timeRequisition No: 820717 Agency: Agency for Health Care Administration Working Title: 68061416 - REGISTERED NURSE SPECIALIST SURVEYOR Pay Plan: Career Service Position Number: 68061416 Salary: $2,010.28 biweekly Posting Closing Date: 05/20/2024 Total C Registered Nurse, Surveyor, Specialist, Registered, Nurse, Healthcare
