Website Orlando Health
Orlando Health is seeking a CDI Specialist III, In this role you will provide concurrent review of the clinical documentation in the medical record; In addition, you will review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures.
- Uses appropriate querying tools (templates) to capture needed documentation.
- 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.
- Documents findings in workflow tools, noting all key information used in the tracking process.
- 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.
- Maintains compliance with all Orlando Health policies and procedures.
- 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.
- Acts as liaison between the Coding Department and the Clinical Documentation Specialist.
- Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Able to identify areas of focus through report analysis.
- 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.
- Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.
- Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record.
- Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
Qualification & Experience:
- Two (2) years previous acute care clinical documentation improvement specialist experience required.
- Thorough knowledge of ICD-9-CM, ICD-10-CM/PCS, APR DRG and MS DRG required.
- Three (3) years of clinical experience in hospital setting with extensive clinical knowledge and understanding of pathology/physiology.
- Graduate from an approved school of medicine, or an RN license from outside the state of Florida.
- Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
- Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
Company: Orlando Health
Vacancy Type: Full Time
Job Location: Lakeland, FL, US
Application Deadline: N/A