Remote CDI Specialist | Corp| Remote bei Orlando Health

Orlando Health | Corp | Documentation Excellence 

Department: Clinical Documentation Excellence   

Shift:Varies 

Location: Remote 

Title: CDI Specialist III

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. 

Forbes has named Orlando Health as one of America's Best-In-State Employers. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions.

“Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.”

Orlando Health proudly embraces and honors the individuality of our team members. By sharing different ideas and perspectives and working together as a team, we are better able to relate to, care for and authentically serve our patients and families who make up the collective populations in our community. So, no matter who you are, what you believe or how you express yourself, you are welcome here.

ORLANDO HEALTH - BENEFITS & PERKS:

Competitive Pay

• Evening, nights, and weekend shift differentials offered for qualifying positions.

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 2021. 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.

Employee-centric

Orlando Health has been selected as one of the “Best Places to Work in Healthcare” by Modern Healthcare.

Essential Functions
• 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.
• Acts as liaison between the Coding Department and the Clinical Documentation Specialist.
• Regularly interacts with/educates physicians to enhance understanding of the CDI program and to ensure the medical record can be coded accurately in order to reflect patient severity of illness and risk of mortality.
• Able to recognize and facilitate performance improvement activities when necessary to achieve benchmark departmental and system metrics.
• 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.

Other Related Functions
 In-depth conceptual and practical knowledge in CDI.
 Solves complex problems.
 Works independently and receives minimal guidance.
 Acts as a resource for team members with less experience.
 May lead teams or have accountability for ongoing activities or objectives.
 Successfully performs a least two assignments related to CDI (see career ladder electives).
 Maintains established work production standards.
 Assumes the responsibility for professional growth and development.
 Ability to work independently in a time-oriented environment.

Education/Training
Graduate from an approved school of nursing.

Licensure/Certification

RN Licensure from FL or a Multistate Nursing Licensure

Must maintain current one of the following:

• Certified Documentation Specialist (CCDS) by the Association of Clinical Documentation Improvement Specialists
• Clinical Documentation Improvement Professional (CDIP) by The American Health Information Management Association
• Certified Professional Coder (CPC) by the American Academy of Professional Coders (AAPC)
• Certified Coding Specialist (CCS)

Experience
• Three (3) years of clinical experience in hospital setting with extensive clinical knowledge and understanding of pathology/physiology.
• Two (2) years previous acute care clinical documentation improvement specialist 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.
• Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.