Clinical Documentation Specialist I

Clinical Documentation Specialist I - Health Central

• Locations: Ocoee, Florida
• Categories: Patient Accounting & Patient Access
• Remote: No
• Division: Orlando Health - Health Central Hospital
• Shift Type: Day
• Facility: Orlando Health - Health Central Hospital
• Req ID: 196212

Job Description:

Position Summary

Health Central Hospital is seeking a CDI Specialist who will provide 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.

The CDI Specialist I will be a Hybrid position. Candidates will be required to work on-site 2 days, and remote 3 days out of the week.

Location 

10000 W Colonial Dr,

Ocoee, FL 34761

Schedule

• Monday - Friday 8am-4:30pm 

Responsibilities

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.
• 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.

Other Related Functions

• 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

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 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.