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Clinical Documentation Excellence, Registered Nurse - ORMC

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Orlando Health

22d ago

  • Job
    Full-time
    Mid Level
  • Healthcare
  • Orlando

AI generated summary

  • You need 3 years of acute care nursing experience, strong clinical knowledge, effective communication skills, and a valid RN license from Florida or eNLC.
  • You will review patient documentation for accuracy, collaborate with departments for quality care representation, clarify medical records with providers, and ensure compliance with documentation standards.

Requirements

  • 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 to write concisely and effectively when communicating with providers.
  • Graduate from an approved school of nursing.
  • Maintains current State of Florida RN license or valid eNLC multistate RN license.

Responsibilities

  • 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.
  • 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 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.
  • Reviews the progress of the CDE program by interpreting performance, process, and quality ratings reports. 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.
  • Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
  • Other duties as assigned.
  • Maintains compliance with all Orlando Health policies and procedures.
  • Performs routine 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 procedures related to CDE.
  • Assumes the responsibility for professional growth and development.
  • Ability to work independently in a time-oriented environment.
  • Receives instruction, guidance, and direction from others.
  • Maintains 100% compliance with all required employee education.

FAQs

What is the job title for this position?

The job title is Clinical Documentation Excellence, Registered Nurse - ORMC.

What is the work schedule for this position?

The position is full-time and operates on a day shift in a hybrid format.

What are the essential responsibilities of this role?

The essential responsibilities include conducting concurrent reviews of clinical documentation, coordinating with various departments to ensure accurate medical records, identifying co-morbidities/complications, and educating providers on documentation importance.

What experience is required for this position?

Three years of acute care hospital nursing experience is required.

What qualifications are necessary for this role?

Candidates must have graduated from an approved school of nursing and maintain a current State of Florida RN license or a valid eNLC multistate RN license.

Are there any benefits offered for this job?

Yes, Orlando Health offers benefits that include student loan repayment, tuition reimbursement, FREE college education programs, paid paternity leave, and more, starting from day one.

What type of training is provided for this position?

The position includes training on clinical documentation excellence concepts and ongoing professional growth and development.

Will I need to work weekends or nights?

The position typically operates during the day shift, but evening, night, and weekend shift differentials are offered for qualifying positions.

How does Orlando Health approach diversity and inclusion?

Orlando Health embraces and honors the individuality of team members, promoting diverse perspectives and ideas to better serve patients and families.

What is the company's recognition regarding workplace culture?

Orlando Health has been named one of America's Best-In-State Employers and recognized as one of the “Best Places to Work in Healthcare” by Modern Healthcare.

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Orlando Health

A trusted leader inspiring hope through the advancement of health.

Science & Healthcare
Industry
10,001+
Employees
1918
Founded Year

Mission & Purpose

Orlando Health is a not-for-profit healthcare organization with $7.6 billion of assets under management that serves the southeastern United States. Headquartered in Orlando, Florida, the system was founded more than 100 years ago.