CDE , RN

Position Summary

Department:
Clinical Documentation Excellence

Shift: Day /Full Time

Location:

Hybrid; based on ORMC campus 2 days a week.

Title:

CDE I

Summary:

Provides concurrent review of clinical documentation in the medical record; reviews the medical record with a clinical lens to identify missing or understated diagnoses or procedures.

• Competitive Pay – Evening, nights, and weekend shift differentials offered for qualifying positions.
• All inclusive benefits from day one, including student loan repayment, tuition reimbursement, free college education programs, retirement savings, paid paternity leave, fertility benefits, backup elder & child care, pet insurance, PTO/Holidays, and more for full‑time and part‑time employees.
• Recognized by Forbes as one of America’s Best‑In‑State Employers (2021).

• Conducts initial and follow‑up concurrent reviews across all hospitals on targeted admissions to clarify documentation and ensure accurate reflection of patient acuity and level of care.
• Coordinates with coding/HIM/UR and other departments to achieve a record that reflects patient acuity and level of care.
• Reviews medical record concurrently for documentation not yet in the record but supported by clinical indicators; performs thorough chart review to identify co‑morbidities/complications and documents these appropriately within the concurrent CDS worksheet; determines the appropriate principal diagnosis.
• Ensures all appropriate secondary diagnoses are captured for quality purposes.
• Documents findings in workflow tools, noting key information for the tracking process.
• Builds relationships and communicates effectively with providers to clarify information in the medical record.
• Uses appropriate clarification tools (templates) to capture needed documentation; submits clarifications to medical staff as necessary by written or verbal communication.
• Provides education to providers and clinicians on importance of complete documentation and key concepts during regular provider meetings or individually with providers, clinicians, and rounds on units.
• Reviews progress of the CDE program by interpreting performance, process, and quality rating reports; identifies areas of focus through report analysis.
• Maintains productivity levels established by the department.
• Attends other educational sessions and designated meetings as assigned.
• Maintains regular, punctual attendance in accordance with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
• Performs other duties as assigned; maintains compliance with all Orlando Health policies and procedures.

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.
• Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in a 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.