CDE RN Clinical Level of Care Review - NICU - Corp

Orlando Health • Orlando, FL

27d • Hybrid

About The Position

Provides concurrent review of the clinical documentation in the medical record, system wide. Reviews the medical record with a clinical lens to identify any missing or understated diagnoses or procedures and ensures the level of care is assigned appropriately by the providers in the NICU population daily compared to system wide approved clinical criteria. Captures the order for the level of care services provided and reviews each chart daily. Direct involvement with clinical teams and uses best practice communication styles to ensure success.
Forbes has named Orlando Health as one of America's Best-In-State Employers. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions.
“Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.”
Orlando Health proudly embraces and honors the individuality of our team members. By sharing different ideas and perspectives and working together as a team, we are better able to relate to, care for and authentically serve our patients and families who make up the collective populations in our community. So, no matter who you are, what you believe or how you express yourself, you are welcome here.

Requirements

• Graduate from an approved RN school of nursing, BSN, required
• Maintains current State of Florida RN license or valid eNLC multistate RN license.
• Minimum of (2) years of acute care hospital NICU RN nursing experience required. Level II and above required.
• Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
• Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

Nice To Haves

• Strong knowledge of the NICU population, Level of Care criteria, treatments, medications and interventions used in this population, preferred, highly recommended

Responsibilities

• Reviews 100% of all NICU babies, system-wide, minimally daily, and as needed throughout the day to ensure the correct Level of Care is ordered based on the clinical criteria established by the hospitals, system wide.
• Uses the established Level of Care criteria (most current) to review the medical records, match Level of Care ordered, and any discrepancies are reconciled with provider/care team of record
• Each NICU baby is reviewed, criteria compared to treatments, medications, interventions documented, or reviewed to ensure accuracy of the level of care.
• Conducts initial and follow-up concurrent reviews across all hospitals on targeted admissions in the NICU 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. Works with providers to capture the appropriate order for the level of care on all NICU populations, system wide.
• Review medical records concurrently for the level of care on the entire NICU population to ensure accuracy of the level of care assigned, discuss opportunities with providers assigned/care team, and update medical record when appropriate based on scope of practice.
• Demonstrates an understanding of the importance of capturing the appropriate level of care for the NICU population and alignment with resources used.
• Documentsfindingsin 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 clarification tools(templates)to capture needed documentation when appropriate. This includes orders for updating the level of care assignment.
• Submit clarifications to 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 providers and clinicians on the importance of complete documentation and key documentation concepts during regular provider meetings or individually with providers, clinicians, rounding on units, etc. when appropriate
• Able to identify areas of focus through report analysis and updates the medical record based on scope of practice.
• Assigned leadership tasks, attends meetings with manager, or assigned by manager as needed.
• Other duties as assigned.
• Acts as a team leader and support for regional manager/assistant manager
• Maintains level of productivity established by department.
• Attends other education sessions and designated meetings as assigned.
• Ability to manage reports, tracking data outcomes, and reporting out changes in the Level of Care on all patients weekly, monthly, quarterly, and/or annually.
• Maintainsreasonably 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.

Benefits

• Competitive Pay
• Evening, nights, and weekend shift differentials offered for qualifying positions.
• All Inclusive Benefits (start day one)
• Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level