CDI Specialist I Registered Nurse
4 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 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.
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Registered Nurse
2 days ago
Syracuse, NY, 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...
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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...
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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...
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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...
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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...
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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...
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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...
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Registered Nurse Specialist I
2 days ago
Orlando, FL, United States University of Central Florida Full timeThe 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 provider, practice nursing...
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CDI SPECIALIST III REGISTERED NURSE
3 weeks 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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Registered Nurse Specialist I
1 day 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...
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CDI RN Specialist
5 days ago
Washington, DC, 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)...
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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...
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CDI RN SPECIALIST
3 weeks ago
, ND, 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...
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CDI RN Specialist
5 days ago
Roseburg, OR, United States Tenet Healthcare Corporation Full timeJOB SUMMARY Responsible 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...
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CDI RN Specialist
5 days ago
Bismarck, ND, United States Tenet Healthcare Corporation Full timeJOB SUMMARY Responsible 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...
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CDI RN SPECIALIST
3 weeks ago
, DC, United States Children's National Hospital 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)...
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CDI RN SPECIALIST
4 weeks ago
, NE, 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...
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CDI RN Specialist
5 days ago
Papillion, NE, United States Tenet Healthcare Corporation Full timeJOB SUMMARY Responsible 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...
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CDI RN Specialist
5 days ago
Omaha, NE, United States Tenet Healthcare Corporation Full timeJOB SUMMARY Responsible 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...
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CDI RN Specialist
5 days ago
Omaha, NE, United States Tenet Healthcare Corporation Full timeJOB SUMMARY Responsible 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...
