RN - Registered Nurse Clinical Documentation Improvement Specialist Senior (CCDS Certification [...]

Geisinger; Danville (PA); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a skilled Clinical Documentation Improvement Specialist to enhance physician documentation in patient medical records. This role involves reviewing medical records, collaborating with healthcare teams, and educating providers to ensure accurate and complete documentation. The ideal candidate will have a strong nursing background, hold relevant certifications, and be committed to improving patient care through meticulous documentation practices. This position offers a supportive work environment with a focus on professional development and patient-centered care, making it an exciting opportunity for those passionate about healthcare documentation.

Benefits

Full benefits (health, dental, vision) starting on day one

401(k) plan with automatic contributions

Generous paid time off (PTO)

Tuition reimbursement up to $5,000 per year

Employee Assistance Program (EAP)

Wellness program with financial incentives

Voluntary benefits including identity theft protection

Qualifications

• 3 years RN work experience required; BSN strongly preferred.
• Must hold CCDS or CDIP certification for consideration.

Responsibilities

• Review and analyze inpatient medical records for documentation accuracy.
• Educate healthcare providers on clinical documentation improvement.

Skills

Clinical Documentation Improvement

Collaboration with Healthcare Providers

Statistical Data Analysis

Education and Training

Education

Bachelor's Degree in Nursing

Graduate from Specialty Training Program-Nursing

Tools

Electronic Health Records (EHR)

Job description

Job Summary: The Clinical Documentation Improvement Program is designed to improve the physician's documentation in the patient's medical record supporting the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Assists the providers with accurately identifying and documenting the healthcare services provided to the patient. Analyzes the clinical information, using the documentation as the primary driver. Acts as documentation liaison to physician staff as a means of finalizing information in the medical record.

Job Duties

• Reviews inpatient medical records within twenty-four to forty-eight hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate assignment, risk of mortality, severity of illness; and initiate documentation of the review.
• Pursues a subsequent review of records every three days to support and assign a working DRG assignment upon discharge.
• Formulates queries when it is determined there is missing documentation, conflicting documentation, or unclear documentation.
• Provides ongoing education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record.
• Collaborates with nursing staff, nutrition, pharmacist, along with the physicians on documentation and to resolve queries prior to the patient's discharge.
• Consistently meets established productivity targets for record review.
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
• Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement.
• Promotes a partnership with the inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures, and completeness of supporting documentation to determine the working and final DRG, severity of illness, and risk of mortality.
• Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age-specific, developmental, cultural, and spiritual needs of the patient.
• Assists with the establishment of training tools for all staff and other employees in regard to quality documentation and coding improvement and further communicates the ongoing improvements relative to process automation, streamline, and employee development.
• Participates in the training of all new staff, including ongoing mentorship.

Work is typically performed in a clinical environment. Accountable for satisfying all job-specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Position Details

Applicants must currently hold the required certification in order to be considered for this position.

Hours: 40 hours per week; Hours will be between 7:00 a.m. and 5:00 p.m. EST

Location: This is a work from home position.

Education and Experience: 3 years RN work experience is required; BSN is strongly preferred

Certification: Must currently hold one of the following certifications- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)

Benefits

• Full benefits (health, dental, and vision) starting on day one
• Three medical plan choices, including an expanded network for out-of-area employees and dependents
• Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA)
• Company-paid life insurance, short-term disability, and long-term disability coverage
• 401(k) plan that includes automatic Geisinger contributions
• Generous paid time off (PTO) plan that allows you to accrue time quickly
• Up to $5,000 in tuition reimbursement per calendar year
• MyHealth Rewards wellness program to improve your health while earning a financial incentive
• Family-friendly support including adoption and fertility assistance, parental leave pay, military leave pay, and a free Care.com membership with discounted backup care for your loved ones
• Employee Assistance Program (EAP): Referrals for childcare, eldercare, & pet care. Access free legal guidance, mental health visits, work-life support, digital self-help tools, and more.
• Voluntary benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life, and pet and legal insurance

Education

Graduate from Specialty Training Program-Nursing (Required), Bachelor's Degree-Nursing (Preferred)

Experience

Minimum of 3 years-Nursing (Required)

Certification(s) and License(s)

Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania; Basic Life Support Certification - Default Issuing Body; Certified Clinical Documentation Specialist - Default Issuing Body; Clinical Documentation Improvement Practitioner - Default Issuing Body