Per Diem CDI Specialist

Orlando Health, Inc.; Orlando (FL); On-site; USD 75,000 - 105,000; Full time

Job summary

Orlando Health, Inc. is seeking a Clinical Documentation Improvement Specialist to provide concurrent review of medical records with a clinical lens.

The role focuses on identifying missing or understated diagnoses or procedures to ensure accurate reflection of patient acuity and level of care. The position requires collaboration with physicians and hospital teams, effective querying, and education to improve documentation quality during routine physician meetings and across departments.

Qualifications

• Must hold a medical degree or an RN license from outside Florida.
• Minimum of three years clinical hospital experience with strong knowledge of pathology/physiology.
• Excellent written and verbal communication skills and concise documentation.

Responsibilities

• Conducts initial and follow-up concurrent reviews to clarify documentation for accurate acuity and level of care.
• Coordinates with coding/HIM/UR and other departments to reflect patient acuity and care level.
• Performs thorough chart reviews to identify comorbidities/complications and documents them in the CDS worksheet.

Skills

Excellent communication skills

Clinical documentation expertise

Querying & physician education

Education

Graduate from an approved school of medicine

RN license (out of state Florida)

Job description

Position 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.

Responsibilities

• 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.
• 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.

Qualifications

Education

• Graduate from an approved school of medicine, or an RN license from outside the state of Florida.

Experience

• Three (3) years of clinical experience in hospital setting with extensive clinical knowledge and understanding of pathology/physiology.
• 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