CDI Specialist I Registered Nurse

4 weeks ago


Orlando Florida, United States Orlando Health Full time
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 

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.

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.



  • Orlando, United States Orlando Health Full time

    CDI 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...


  • Orlando, United States Orlando Health Full time

    CDI 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...


  • Orlando, FL, United States Orlando Health Full time

    CDI 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...


  • Orlando, FL, United States Orlando Health Full time

    CDI 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...


  • Orlando, FL, United States Orlando Health Full time

    CDI 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...


  • Orlando, FL, United States Orlando Health Full time

    CDI 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...


  • Orlando, Florida, United States Orlando Health Full time

    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...


  • Orlando, FL 32801, USA, United States Orlando Health Full time

    Position 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...


  • Sarasota, Florida, United States Travel Hire Full time

    Job Description Department Revenue Cycle Job Summary The Clinical Documentation Integrity Lead is responsible for assisting and supporting leadership in planning, directing, and controlling all aspects of the day-to-day operations for the Clinical Documentation Integrity (CDI) program by establishing a collaborative rapport with CDI Specialists,...

  • Mental Health Tech I

    2 weeks ago


    Orlando, Florida, United States Orlando Health Full time

    Position Summary: South Seminole Hospital   Position 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).   Shift: POOL/Days & Nights  Responsibilities:  Documents observations on assigned patients in legible,...


  • Orlando, Florida, United States Orlando Health Full time

    Position Summary: Orlando Health is seeking an Account Payable Specialist I. This role will process vendor invoices (electronic and paper) in various systems with attention to detail, reasonableness and appropriate authorization.   Location:  45 W. Crystal Lake St  Orlando, FL 32806   Schedule:  Monday-Fri...

  • Company Nurse

    4 days ago


    Orlando, FL, United States University of Central Florida Full time

    Registered Nurse Specialist I (TEMP) 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,...

  • Registered Nurse

    3 weeks ago


    Orlando, United States Vitas Healthcare Full time

    Registered 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...


  • Orlando, Florida, United States Orlando Health Full time

    Position Summary: Provides quality patient care when performing diagnostic cardiology and/or vascular sonographic imaging and related procedures to demonstrate anatomy for interpretation and/or intervention under the supervision of the department supervisor, manager, or director. • Demonstrates competency in routine noninvasive and/or invasive cardiology...

  • EHS Specialist I

    2 weeks ago


    Orlando, Florida, United States Nautique Boat Company Full time

    Job Description Take your career to the next level! Join a company that values people, performance and philanthropy and is passionate about making a difference in the world. If you are a resourceful individual who thrives on challenges while working in a fast paced, high volume environment, this may be the ideal job for you! Summary: The Environmental...

  • Registered Nurse

    3 weeks ago


    Orlando, Florida, United States Orlando Health Full time

    Position Summary: Med Surg/Inpatient Acute Care Rehab Nursing Who are we: • Commission on Accreditation of Rehabilitation Facilities (CARF International Accreditation)- more than 25 years • Specialty Rehabilitation Registered nurses – currently 68% CRRN certified • Patient population – strokes, traumatic brain injury, multiple injuries, new...


  • Orlando, Florida, United States Orlando Health Full time

    Position Summary: The Patient Accounts Specialist I is responsible for accurately billing patient accounts, ensuring timely submission and reimbursement from various third-party payers and patients, ensuring proper account documentation in the facility’s billing system, and pursuing follow-up efforts on aged accounts. Responsibilities: • Determine...

  • Registered Nurse

    1 week ago


    Orlando, Florida, United States Orlando Health Full time

    Position 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...


  • Orlando, United States Orlando Health Full time

    Position Summary South Seminole Hospital Position 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). Shift: POOL/Days & Nights Responsibilities Documents observations on assigned patients in legible, accurate and...


  • Orlando, Florida, United States Quality Talent Group Full time

    Position OverviewThe Registered Nurse is responsible for providing and documenting skilled nursing care in accordance with the developed care plan and physiciansâ orders for each individual patient while adhering to confidentiality standards and professional boundaries at all times.PRN visits needed in Orange, Seminole, and Osceola counties -...