CDE II, RN

Position Summary Department: Clinical Documentation Excellence Shift: Day / Full Time Location: Remote Title: CDE II, RN At Orlando Health, we are ordinary people with extraordinary individuality, working together to bring help, healing and hope to those we serve. By daily embodying our over 100-year legacy, we reinforce our reputation as a trusted and respected healthcare organization that delivers professional and compassionate care to our patients, families and communities.

Through our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida’s east to west coasts and beyond. ORLANDO HEALTH - BENEFITS & PERKS: All Inclusive Benefits (start day one) 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 Recognizes Orlando Health as a Best-In-State Employer Forbes has named Orlando Health as one of America's Best-In-State Employers for 2024. 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.

A Brief Overview 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. 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. 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 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 CDE ladder expectations assigned to a Level II CDE, RN role. 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 Successfully performs and maintains required assignments noted in the most current CDE ladder established. Has working knowledge and experience in Clinical Documentation Excellence (CDE). Continues to build knowledge of the organization, customers and CDE processes. Maintain established work production standards and attendance with no performance improvement documented in system.

Utilizes prescribed guidelines or policies to analyze and resolve issues. Receives a moderate level of guidance and direction. Assumes the responsibility for professional growth and development. Ability to work independently in a time-oriented environment. 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) years acute care hospital nursing experience required.

One (1) year of acute care CDE experience required. Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG required. 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.

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. 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 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 CDE ladder expectations assigned to a Level II CDE, RN role. 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 Successfully performs and maintains required assignments noted in the most current CDE ladder established. Has working knowledge and experience in Clinical Documentation Excellence (CDE). Continues to build knowledge of the organization, customers and CDE processes. Maintain established work production standards and attendance with no performance improvement documented in system. Utilizes prescribed guidelines or policies to analyze and resolve issues. Receives a moderate level of guidance and direction. Assumes the responsibility for professional growth and development. Ability to work independently in a time-oriented environment.

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) years acute care hospital nursing experience required. One (1) year of acute care CDE experience required. Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG required. 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.