Texas Health Huguley FWS
Clinical Documentation Second Level Reviewer I
Texas Health Huguley FWS, Orlando, Florida, us, 32885
Overview
Clinical Documentation Second Level Reviewer I (Job Number: 25036946) Responsibilities
Under general supervision of the Director of Clinical Documentation Integrity and, in some situations, the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Second Level Reviewer I strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The Second Level Reviewer I educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management. The Second Level Reviewer I adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Reviews concurrent medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality. Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars. The value you’ll bring to the team
Reviews concurrent medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality. Completes accurate and timely input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. (same as above) Qualifications
The expertise and experiences you’ll need to succeed : Five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. BSN and 3 years of Clinical Documentation Specialist experience OR 4 years of recent Clinical Documentation Specialist experience OR Less than 2 years of Clinical Documentation Integrity experience and 10 years of acute care nursing experience Current active State license as a Registered Nurse, Nurse Practitioner, Physician’s Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation CCDS (Certified Clinical Documentation Specialist) certification or CDIP (Certified Documentation Improvement Practitioner) certification and 2 years of Clinical Documentation Integrity experience
#J-18808-Ljbffr
Clinical Documentation Second Level Reviewer I (Job Number: 25036946) Responsibilities
Under general supervision of the Director of Clinical Documentation Integrity and, in some situations, the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Second Level Reviewer I strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The Second Level Reviewer I educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management. The Second Level Reviewer I adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Reviews concurrent medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality. Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars. The value you’ll bring to the team
Reviews concurrent medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality. Completes accurate and timely input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. (same as above) Qualifications
The expertise and experiences you’ll need to succeed : Five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience. BSN and 3 years of Clinical Documentation Specialist experience OR 4 years of recent Clinical Documentation Specialist experience OR Less than 2 years of Clinical Documentation Integrity experience and 10 years of acute care nursing experience Current active State license as a Registered Nurse, Nurse Practitioner, Physician’s Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation CCDS (Certified Clinical Documentation Specialist) certification or CDIP (Certified Documentation Improvement Practitioner) certification and 2 years of Clinical Documentation Integrity experience
#J-18808-Ljbffr