Registered Nurse Documentation Quality Review FT Days at AdventHealth

Date Posted: 12/24/2020

Job Snapshot

  • Job Schedule
    Full-Time
  • Location:
    Maitland, FL
  • Date Posted:
    12/24/2020
  • Job ID:
    20029995
  • Job Family
    Health Information Management
  • Travel
    No
  • Shift
    1 - Day

Job Description


Description

Documentation Quality Reviewer AdventHealth Trickel

 
Location Address: 900 Winderley Place, Maitland,FL 32751
Top Reasons to work at AdventHealth 
  • Great benefits
  • Immediate Health Insurance Coverage
  • Career growth and advancement potential
 
 
Work Hours/Shift:
  • Full Time: M-F 8-5
 

You Will Be Responsible For:   

  • Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.
  • Conducts audits for quality including, but not limited to deceased second level reviews, focused disease process reviews as needed, patient safety indicators, CDI team audits. Collects data, analyzes data and reports data to CDI Director and CDI Leadership team.
  • Completes accurate and timely record review. Recognizes opportunities for documentation improvement.
  • Educates members of the patient-care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and care management.
  • Initiates CDMP severity worksheet for inpatients.
  • Effectively and appropriately communicates with physicians.

Qualifications
What Will You Need:        
 

EDUCATION AND EXPERIENCE REQUIRED:

 

EDUCATION AND EXPERIENCE PREFERRED:

  • Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU
  • BSN or MSN
 

LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:

  • Current valid State of Florida or multi state license as a Registered Nurse
 

LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:

  • CCDS, CDIP, CCS
 
Job Summary:

Under general supervision of the Director of Clinical Documentation Integrity, and in collaboration with physicians, nursing and HIM coders, the Documentation Quality Reviewer (DQR), is responsible for reviewing medical records for quality and core measures. The DQR 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, and to support ICD-10 codes. The DQR collects data, analyzes data and reports data to CDI Director. The DQR educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and care management. The DQR will act as a liaison to the CDI and coding staff. The DQR will serve as a resource to the CDI team, CDI Educator, CDI Managers and CDI Director. The DQR adheres to 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.



This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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