Remote HIM CDI Clinical Documentation Specialist

Penn Medicine; Bala Cynwyd (PA); On-site; USD 70,000 - 90,000; Full time

Job summary

Penn Medicine is seeking a Clinical Documentation Specialist to support organization-wide documentation improvements. You will prompt clinicians for complete documentation, teach compliant coding practices, and ensure the medical record accurately reflects patient condition and severity.

Under supervision of Corporate CDI leadership, you will analyze trends, educate care teams, and coordinate DRG assignments while maintaining strict HIPAA standards.

Qualifications

• Bachelor's degree is required.
• 3+ years of healthcare experience is required.
• Master's degree is preferred.
• RN, NP, or PA licensure is required.
• Clinical experience with Medicare reimbursement system & coding structures is preferred.

Responsibilities

• Direct review of patient charts to audit clarity and full reflection of severity in care team documentation per CMS guidelines.
• Provide ongoing education and training on documentation trends for clinical teams.
• Collaborate with Corporate Manager of Clinical Documentation Improvement to improve departmental efficiencies.
• Enter clinical review data in EPIC PENN Chart to reflect current state and DRG assignments.
• Generate compliant queries to obtain diagnostic clarity and improve documentation accuracy.
• Ensure concurrent inpatient documentation reflects severity of illness and service intensity.
• Document POA status within regulatory timeframes.
• Coordinate with physicians for appropriate documentation and DRG assignments.
• Maintain HIPAA compliance in all reviews.
• Participate in professional development through workshops and training.

Skills

Clinical documentation

CMS coding guidelines

HIPAA knowledge

Communication skills

Education

RHIA

RHIT

CCS

CCDS

CDIP

RN license

NP license

PA license

Bachelor's degree

Master's degree

Job description

Penn Medicine is seeking a Clinical Documentation Specialist to support organization-wide documentation improvements. You will prompt clinicians for complete documentation, teach compliant coding practices, and ensure the medical record accurately reflects patient condition and severity.

Under supervision of Corporate CDI leadership, you will analyze trends, educate care teams, and coordinate DRG assignments while maintaining strict HIPAA standards.