Remote HIM CDI Specialist: Elevate Clinical Documentation

Penn Medicine; Bala Cynwyd (PA); Remote; USD 70,000 - 100,000; Full time

Job summary

Penn Medicine is seeking a Clinical Documentation Specialist to support an organization-wide system for improving clinical documentation in the medical record. You will prompt physicians to ensure complete and accurate documentation in line with CMS guidelines and to ensure the chart reflects the severity of illness and treatment.

Reporting to Corporate HIM CDI, you will educate clinical teams, analyze trends, and maintain HIPAA compliance while improving documentation efficiencies across care

Qualifications

• Bachelor's degree is required.
• 3+ years of healthcare experience is required.
• RN, NP, or PA licensure is required.
• RHIA, RHIT, and CCS certifications are preferred.
• Master's degree 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 and coding trends to clinical care teams.
• Collaborate with the Corporate Manager of Clinical Documentation Improvement to improve efficiencies within the department.
• Enter clinical review data in EPIC PENN Chart to reflect current state and assign Initial DRG and Working DRG.
• Generate compliant, non-leading queries to obtain necessary documentation and diagnostic clarity.
• Ensure POA status and accuracy of inpatient documentation within regulatory timeframes.
• Coordinate with physicians to obtain appropriate documentation for DRG assignment and coding.

Skills

CMS coding guidelines

Clinical documentation

EPIC Penn Chart

DRG concepts

Education

Bachelor's degree

3+ years healthcare experience

Master's degree preferred

Tools

EPIC Penn Chart

HIM/CDI tools

Job description

Penn Medicine is seeking a Clinical Documentation Specialist to support an organization-wide system for improving clinical documentation in the medical record. You will prompt physicians to ensure complete and accurate documentation in line with CMS guidelines and to ensure the chart reflects the severity of illness and treatment.

Reporting to Corporate HIM CDI, you will educate clinical teams, analyze trends, and maintain HIPAA compliance while improving documentation efficiencies across care