CDE I, RN
6 days ago
Position Summary
Orlando Health - Southlake Hospital
Department: Clinical Documentation Excellence - Corp
Status: Variable Full Time
Shift: varies
Title: RN Clinical Documentation Excellence Specialist I
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.
Location: OH Southlake Hospital
Forbes has named Orlando Health as one of America's Best-In-State Employers. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions.
"Orlando Health Is Your Best Place to Work" is not just something we say, it's our promise to you.
ORLANDO HEALTH - BENEFITS & PERKS:
Competitive Pay
- Evening, nights, and weekend shift differentials offered for qualifying positions.
- Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees.
- Forbes has named Orlando Health as one of America's Best-In-State Employers for 2021. Orlando Health is the top healthcare organization in the Metro Orlando area to make the prestigious list. "We are proud to be named once again as a best place to work," said Karen Frenier, VP (HR). "This achievement reflects our positive culture and efforts to ensure that all team members feel respected, supported and valued.
- 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 or individually 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.
Qualifications
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.
-
CDE I, RN
4 days ago
Orlando, United States Orlando Health Full timeCDE I, RN - Orlando Health Southlake HospitalPosition Summary Orlando Health - Southlake Hospital Department: Clinical Documentation Excellence - Corp Status: Variable Full Time Shift: varies Title: RN Clinical Documentation Excellence Specialist I Summary: Provides concurrent review of the clinical documentation in the medical record; review the medical...
-
Registered Nurse I
2 months ago
Orlando, United States OneBlood Full timeRegistered Nurse I Overview Under the direction of the Chief Medical Officer, and the Manager or Director Nursing, has the responsibility to perform clinical apheresis procedures Responsibilities The list of essential functions, as outlined herein, is intended to be representative of the duties and responsibilities performed within this classification. It...
-
Registered Nurse RN CVSD
2 months ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription IntroductionDo you have the career opportunities as a(an) Registered Nurse RN CVSD you want with your current employer? We have an exciting opportunity for you to join HCA Florida Osceola Hospital which is part of the nation's leading provider of healthcare services, HCA Healthcare.BenefitsHCA Florida Osceola Hospital, offers a total rewards...
-
Lead Charge Nurse
5 months ago
Orlando, United States Fresenius Medical Care North America Full timePURPOSE AND SCOPE: Supports FMCNA’s mission, vision, core values and customer service philosophy. Adheres to the FMCNA Compliance Program, including following all regulatory and FMS policy requirements. Ensure quality patient care while maintaining cost-effective clinical operations in accordance with all legal, compliance, and regulatory requirements and...
-
Medical Support Specialist RN
4 weeks ago
Orlando, United States Biolife Plasma Services Full timeJob DescriptionBy clicking the “Apply” button, I understand that my employment application process with Takeda will commence and that the information I provide in my application will be processed in line with Takeda’s Privacy Notice and Terms of Use. I further attest that all information I submit in my employment application is true to the best of my...
-
Medical Support Specialist RN
2 months ago
Orlando, United States Biolife Plasma Services Full timeJob DescriptionBy clicking the “Apply” button, I understand that my employment application process with Takeda will commence and that the information I provide in my application will be processed in line with Takeda’s Privacy Notice and Terms of Use. I further attest that all information I submit in my employment application is true to the best of my...
-
Registered Nurse RN PACU
2 months ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription IntroductionAre you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a(an) Registered Nurse RN PACU today with HCA Florida Osceola Hospital.BenefitsHCA Florida Osceola Hospital, offers a total rewards package that...
-
Registered Nurse RN OB
5 months ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription IntroductionAre you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a(an) Registered Nurse RN OB today with HCA Florida Osceola Hospital.BenefitsHCA Florida Osceola Hospital, offers a total rewards package that supports...
-
Nursing Assistant I
7 days ago
Orlando, United States Orlando Health Full timePosition Summary Performs general patient care to patients under the direction and supervision of the Licensed Practical Nurse or Registered Nurse. Qualifications Education/Training High school graduate or equivalent. Licensure/Certification Must obtain BLS/Healthcare Provider certification within 30 days of hire. Experience None Responsibilities Essential...
-
Nursing Assistant I
2 months ago
Orlando, United States Orlando Health Full timePosition Summary Performs general patient care to patients under the direction and supervision of the Licensed Practical Nurse or Registered Nurse. Responsibilities Essential Functions Assists patient with hygiene, mobility, hydration, elimination and nutritional needs Provides routine treatments and maintains a safe, clean, neat, and organized patient...
-
Mental Health Tech I
2 weeks ago
Orlando, United States Orlando Health Full timePosition Summary Performs general nursing care to patients in a manner that considers safety, comfort, and the therapeutic environment under the direction and supervision of the Registered Nurse (RN). Orlando Health is home to Orlando Health Behavioral Healthcare, an 80-bed psychiatric hospital. We offer comprehensive services for people suffering from...
-
Registered Nurse RN Neuro Trauma ICU
3 weeks ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription Introduction Do you have the career opportunities as a(an) Registered Nurse RN Neuro Trauma ICU you want with your current employer? We have an exciting opportunity for you to join HCA Florida Osceola Hospital which is part of the nation's leading provider of healthcare services, HCA Healthcare. Benefits HCA Florida Osceola Hospital, offers a...
-
Registered Nurse RN Special Procedures PRN
4 weeks ago
Orlando, United States HCA Florida Poinciana Hospital Full timeDescription IntroductionHCA Florida Poinciana Hospital is committed to investing in the latest technology enabling nurses to work more efficiently. Are you passionate about delivering patient-centered care? Submit your application for Registered Nurse RN Special Procedures position and spend more time at the bedside with the patient.BenefitsHCA Florida...
-
Lead Charge Nurse
5 months ago
ORLANDO, United States Fresenius Medical Care Full timePURPOSE AND SCOPE:Supports FMCNA’s mission, vision, core values and customer service philosophy. Adheres to the FMCNA Compliance Program, including following all regulatory and FMS policy requirements. Ensure quality patient care while maintaining cost-effective clinical operations in accordance with all legal, compliance, and regulatory requirements and...
-
Registered Nurse RN Labor and Delivery
5 months ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription IntroductionAre you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a(an) Registered Nurse RN Labor and Delivery today with HCA Florida Osceola Hospital.BenefitsHCA Florida Osceola Hospital, offers a total rewards...
-
Registered Nurse RN Med Surg
4 months ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription IntroductionAre you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a(an) Registered Nurse RN Med Surg today with HCA Florida Osceola Hospital.BenefitsHCA Florida Osceola Hospital, offers a total rewards package that...
-
Registered Nurse RN Operating Room
4 weeks ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription IntroductionDo you want to join an organization that invests in you as a(an) Registered Nurse RN Operating Room? At HCA Florida Osceola Hospital, you come first. HCA Healthcare has committed up to $300 million in programs to support our incredible team members over the course of three years.BenefitsHCA Florida Osceola Hospital, offers a total...
-
Registered Nurse RN Pre Post EP Lab
4 weeks ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription IntroductionDo you want to join an organization that invests in you as a(an) Registered Nurse RN Pre Post EP Lab? At HCA Florida Osceola Hospital, you come first. HCA Healthcare has committed up to $300 million in programs to support our incredible team members over the course of three years.BenefitsHCA Florida Osceola Hospital, offers a total...
-
Registered Nurse RN Neuro Trauma ICU PRN
1 month ago
Orlando, United States HCA Florida Osceola Hospital Full timeDescription Introduction Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a(an) Registered Nurse RN Neuro Trauma ICU PRN today with HCA Florida Osceola Hospital. Benefits HCA Florida Osceola Hospital, offers a total rewards...
-
Hospital at Home RN
4 months ago
Orlando, United States Health First Full timePOSITION SUMMARY: In alignment with Health First commitments of Quality/No Harm, Customer Service and Stewardship goals, the Hospital at Home (HaH) RN demonstrates clinical expertise through the assessment, planning, implementation and evaluation of patient care according to the standards of professional nursing practice. The HaH RN will collaborate with the...
