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Surgery Jobs at Orlando Health

By being hired into one of our Surgery jobs at Orlando Health, you’ll be a key member of the Orlando Health team. Professionals in Surgery careers come from a variety of backgrounds, bringing an assortment of knowledge and skills to every area of our business. Please click on your desired Surgery job below to learn more about the exact qualifications. A job in Surgery at Orlando Health may be waiting for you!

Clinical Documentation Specialist, RN

Job ID 130925 Date posted 06/09/2016 Facility Orlando Health Corporate

Orlando Health is a $2.3 billion not-for-profit health care organization, a community-based network of hospitals and care centers in the Orlando region and home to one of the largest tertiary facilities and Central Florida's only Level One Trauma Center, designated as a "Trauma Program of Excellence . As a family of specialty and community hospitals, each has its own character, a natural extension of the specialized services offered. It is our mission that unifies us to offer superior service and provide quality healthcare to the people of Central Florida. Our 1,780-bed hospital system includes Arnold Palmer Hospital for Children, Winnie Palmer Hospital for Women, UF Cancer Center Orlando, Dr. P. Phillips Hospital, South Seminole Hospital and Orlando Regional Medical Center; Teaching Hospital and Central Florida's only Level One Trauma Center.

Orlando Health has an opening for a Clinical Documentation Specialist, RN or medical school graduate with pediatric and/or neonatal experience. Qualified candidates will have the following education/experience:

Graduate of an approved school of nursing or medical school

Five (5) years acute care hospital RN or medical graduate 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.

Certified Clinical Documentation Specialist ( CCDS) / Certified Documentation Improvement Professional ( CDIP) certification preferred.

This is an On-site position which may require travel to other facilities.

Responsibilities include:

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 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.

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Orlando Health is an equal opportunity employer. In accordance with applicable law, we prohibit discrimination based on race, color, sex, national origin, religion, gender, sexual orientation, marital status, disability, age, veteran status, gender identity, or any other consideration protected by federal, state, or local laws. Our commitment to equal opportunity employment applies to all persons involved in our operations and prohibits unlawful discrimination by any team member, including supervisors and coworkers.

In determining suitability for employment, no consideration will be given to an applicant’s age, race, sex, color, religion, marital status, citizenship status, national origin, disability, or any other protected characteristic. Applicants with disabilities will be given full consideration based on their abilities to perform the essential job function, with or without a reasonable accommodation.