Clinical Documentation Integrity I Elevate Care Data

WellSpan Health; York (York County); On-site; USD 75,000 - 110,000; Full time

Benefits offered by this job

Health benefits

Retirement plan

PTO

Education assistance

DailyPay

Parental leave

Job summary

WellSpan Health seeks a CDI specialist to enhance the quality and completeness of provider documentation in the medical record. You will work with treating providers, HIM coding staff, and CDS teams to ensure documentation reflects illness severity and services rendered for appropriate reimbursement.

Responsibilities include DRG assignment reviews, concurrent/retrospective reviews, and provider queries to improve documentation quality. Strong collaboration with CDS and coding teams is essential.

Qualifications

• Nursing degree or equivalent required/Preferred per listing.
• CDI experience in acute care facility is required or preferred.
• RN/MD/DO licensure upon hire is required or: multi-state license acceptable.
• CDS certification encouraged or preferred.
• Experience with APR-DRG encoder and coding collaboration beneficial.

Responsibilities

• Review hospitalized medical records to identify principal diagnosis and assign DRG.
• Perform initial, concurrent, and retrospective reviews to ensure accuracy of DRG.
• Conduct chart reviews using comprehensive source data to support coding.
• Query providers to clarify documentation per guidelines and follow through to closure.
• Collaborate with coding staff to ensure complete documentation for accurate coding.

Skills

Organized

Analytical

PowerPoint

Excel

Communication

Education

Diploma Program in Nursing

Associates Degree in Nursing

Doctor of Medicine (MD)

Doctor of Osteopathic Medicine (DO)

Bachelors Degree Preferred

Tools

PowerPoint

Excel

Microsoft Office

Job description

WellSpan Health seeks a CDI specialist to enhance the quality and completeness of provider documentation in the medical record. You will work with treating providers, HIM coding staff, and CDS teams to ensure documentation reflects illness severity and services rendered for appropriate reimbursement.

Responsibilities include DRG assignment reviews, concurrent/retrospective reviews, and provider queries to improve documentation quality. Strong collaboration with CDS and coding teams is essential.