CDI Specialist III Registered Nurse
2 weeks ago
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 role 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. 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 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.
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CDI Specialist III Registered Nurse
2 weeks 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...
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CDI Specialist III Registered Nurse
Found in: Jooble US O C2 - 2 weeks ago
Orlando, FL, United States Orlando Health Full timeCDI Specialist III Registered Nurse - Clinical Documentation - Orlando Health 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 role Responsibilities Conducts initial and follow-up...
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CDI Specialist III Registered Nurse
Found in: Jooble US O C2 - 2 weeks ago
Orlando, FL, United States Orlando Health Full timeCDI Specialist III Registered Nurse - Clinical Documentation - Orlando Health 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 role Qualifications Education/Training Graduate...
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CDI Specialist III Registered Nurse
2 weeks 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...
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CDI SPECIALIST III REGISTERED NURSE
Found in: Careerbuilder One Red US C2 - 4 days ago
Orlando, FL 32801, USA, United States Orlando Health Full timePosition 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.QualificationsEducation/TrainingGraduate from an approved school of nursing.Licensure/CertificationMaintains current State of Florida RN license or valid...
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CDI Specialist I Registered Nurse
Found in: Resume Library US A2 - 1 week ago
Orlando, Florida, 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. This is a hybrid role, location ORMC Hospital Responsibilities: Conducts initial and follow-up concurrent reviews on targeted admissions for...
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CDI Specialist I Registered Nurse
Found in: Resume Library US A2 - 1 week ago
Orlando, Florida, 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. This is a hybrid role, location ORMC Hospital Qualifications: Education/Training Graduate from an approved school of...
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CDI Specialist I Registered Nurse
Found in: Resume Library US A2 - 2 weeks ago
Orlando, Florida, 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. This is a hybrid position, hospital will be Arnold Palmer Childrens Hospital Responsibilities: Conducts initial and follow-up concurrent...
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CDI Specialist I Registered Nurse
Found in: Resume Library US A2 - 2 weeks ago
Orlando, Florida, 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. This is a hybrid position, hospital will be Arnold Palmer Childrens Hospital Qualifications: Education/Training Graduate from an approved...
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Fire Report Specialist I/II/III
Found in: beBee jobs US - 2 weeks ago
Orlando, Florida, United States City of Orlando Full timeDescription Who We AreOrlando, The City BeautifulFor most of Orlando's history we've been the place everyone wants to visit. Today, we're also the place where everyone wants to live and do business. List after list has Orlando as one of the fastest growing cities in America. We're transitioning from our role as the young upstart to a more mature, global...
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PLANT SPECIALIST TRAINEE/ I/II/III
Found in: Careerbuilder One Red US C2 - 12 hours ago
Orlando, FL 32801, USA, United States Orange County, FL Full timeOverviewAt Orange County Government, we are proud to serve the public with integrity, honesty, fairness, andprofessionalism. We develop innovative policies and services that impact Central Florida and shape the futureof our community.Orange County Utilities provides water resources and solid waste recovery services to protect and enrich thelives of the...
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Periop Support Assoc III
Found in: Resume Library US A2 - 1 week ago
Orlando, Florida, United States Orlando Health Full timePosition Summary: Performs the duties of the PSA I and II, plus specialty specific advanced field support skills. Responsibilities: Essential Functions May assist surgeon at surgical field by passing instrumentation at skin closure once the counts are completed and specimens are removed. May be the primary scrub on closed procedures, splint and cast...
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Director of Nursing
5 days ago
Orlando, United States MaeBrooks Healthcare Services Full timeMaeBrooks Healthcare Services - Director of Nursing (DON) / Registered Nurse (RN) We are seeking an excellant RN (Registered Nurse) to be our DON (Director of Nursing) in our skilled nursing facility located in the Orange County area. Excellant Benefits Competitive Pay Supportive Leadership Experience Required of the Director of Nursing (DON) / Registered...
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7 days ago
Orlando, United States Mind and Mobility Full timeJob DescriptionJob DescriptionDescription:MIND & MOBILITY HOME CARE provides superior in-home care that promotes physical, psychological, and social engagement which allows the client to thrive as they age in their home. This position is for Orange County.Registered Nurse Responsibilities:Evaluation clients personal care and ADLsEstablishing a competent...
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1 week ago
Orlando, United States Vitas Healthcare Full timeRegistered Nurse (RN)PRIMARY FUNCTION The Registered Nurse, RN, is a member of the interdisciplinary team who work together to meet the physical, medical, psychosocial, emotional and spiritual needs of hospice patients and families facing terminal illness and bereavement. The Registered Nurse, RN, is designated to provide coordination of care, ensure...
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Registered Nurse RN ICU
Found in: Lensa US P 2 C2 - 5 days ago
Orlando, United States Tampa General Hospital Full timeJob Description - Registered Nurse RN ICU (23000425) Job Description Registered Nurse RN ICU ( Job Number: 23000425 ) Description TGH Brooksville & Spring Hill are a 244-bed Health System Joint Commission, Accredited Chest Pain Center, and Primary Stroke Center. TGH Brooksville care services include a surgery program, a dedicated orthopedic joint replacement...
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Registered Nurse RN ICU
Found in: Lensa US P 2 C2 - 5 days ago
Orlando, United States Tampa General Hospital Full timeJob Description - Registered Nurse RN ICU (23000425)Job DescriptionRegistered Nurse RN ICU ( Job Number: 23000425 )DescriptionTGH Brooksville & Spring Hill are a 244-bed Health System Joint Commission, Accredited Chest Pain Center, and Primary Stroke Center. TGH Brooksville care services include a surgery program, a dedicated orthopedic joint replacement...
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Registered Nurse
Found in: Lensa US P 2 C2 - 5 days ago
Orlando, United States Orlando Health Full timePosition Summary:Orlando Health Winnie Palmer Hospital for Women & BabiesLocated on the downtown Orlando campus, Orlando Health Winnie Palmer Hospital for Women & Babies opened in 2006, providing programs and services focused on the unique needs of women and newborns. Specialized care covers all facets of women's health, from comprehensive gynecological...
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Registered Nurse- Women's ICU
Found in: Lensa US P 2 C2 - 2 weeks ago
Orlando, United States Orlando Health Full timePosition Summary: Orlando Health Winnie Palmer Hospital for Women & Babies Located on the downtown Orlando campus, Orlando Health Winnie Palmer Hospital for Women & Babies opened in 2006, providing programs and services focused on the unique needs of women and newborns. Specialized care covers all facets of women's health, from comprehensive gynecological...
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Registered Nurse
1 week ago
Orlando, United States Luxus Full timeJob DescriptionJob DescriptionTitle: Rehabilitation NurseLocation: Orlando, FLOverview: Join our esteemed healthcare team as a Rehabilitation Nurse , recognized for its excellence in patient care and innovative rehabilitation services. As a Rehabilitation Nurse, you will play a crucial role in providing specialized nursing care to patients undergoing...