Registered Nurse Documentation Quality Review FT Days

Documentation Quality Reviewer AdventHealth Trickel

• Great benefits
• Immediate Health Insurance Coverage
• Career growth and advancement potential

• 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.

EDUCATION AND EXPERIENCE REQUIRED:

• Two (2) years of Clinical Documentation Specialist experience 
• Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU

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

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.