Department: Clinical Documentation Excellence Shift: Day / Full Time Location: Lakeland, FL Title: CDE I, RN Position Summary Conducts initial and follow-up concurrent reviews across multiple hospitals on targeted admissions for opportunities to clarify and/or validate documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care. Essential Functions Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided. Reviews medical records for documentation not yet in the record but supported by clinical indicators. Performs a thorough chart review to determine the appropriate principal diagnosis and to identify and/or validate co-morbidities/complications, documenting these appropriately within the current CDS software tool. Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate diagnoses for an accurate and ...