Clinical Documentation Excellence Specialist

4 weeks ago


Orlando, Florida, United States Orlando Health Full time

Are you a detail-oriented and organized nurse looking to advance your career in clinical documentation excellence? We are seeking a skilled Clinical Documentation Excellence Specialist to join our team at Orlando Health.

We offer a competitive salary of $85,000 - $110,000 per year, depending on experience. Our comprehensive benefits package includes all-inclusive benefits, 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.

Job Summary:

  • 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.

Responsibilities:

  1. Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet.
  2. Determines the appropriate principal diagnosis of the patient.
  3. Maintains levels of productivity established by department.

Requirements:

  • Graduate from an approved school of nursing.
  • Maintains current State of Florida RN license or valid eNLC multistate RN license.
  • Three (3) year acute care hospital nursing experience required.

Benefits:

  • Competitive salary
  • All-inclusive benefits
  • 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


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