RN - Registered Nurse Clinical Documentation Improvement Specialist Senior (Certification Required)

Geisinger; Pennsylvania; Remote; USD 60,000 - 90,000; Full time

Job summary

An established healthcare provider is seeking a Clinical Documentation Specialist to enhance the quality of patient records. This exciting role involves reviewing medical documentation, collaborating with healthcare teams, and providing education to ensure accurate clinical documentation. The position offers a unique opportunity to impact patient care positively while working from home. The organization values its employees, offering a comprehensive benefits package that includes health coverage from day one, generous paid time off, and support for professional development. If you are passionate about improving healthcare documentation and enjoy working in a collaborative environment, this role is perfect for you.

Benefits

Full benefits starting on day one

401(k) plan with contributions

Generous paid time off

Tuition reimbursement up to $5,000

Employee Assistance Program (EAP)

Wellness program with financial incentives

Family-friendly support programs

Company-paid life insurance

Short-term and long-term disability coverage

Voluntary benefits options

Qualifications

• Must hold CCDS or CDIP certification.
• 3 years of RN experience required, BSN preferred.

Responsibilities

• Review inpatient medical records for accurate diagnosis assignment.
• Provide education to healthcare providers on documentation improvement.
• Collaborate with the interdisciplinary team for patient care.

Skills

Clinical Documentation Improvement

Collaboration with Healthcare Professionals

Statistical Data Analysis

Education and Training

Education

Bachelor of Science in Nursing (BSN)

3 years RN work experience

Tools

Electronic Health Records (EHR)

Job description

• 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 on-going 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 on-going 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.

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)

Geisinger cares about not only its patients and members, but also about you and your family. We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally. We believe in creating a diverse and inclusive environment where all employees can be their authentic selves.

• 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