Clinical Documentation Improvement Specialist Registered Nurse (Rn)

Job Summary

The Clinical Documentation Improvement Program (CDI) 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. The role of the Clinical Documentation Improvement Specialist (CDIS) is to assist the providers with accurately identifying and documenting the healthcare services provided to the patient. This is accomplished with the recognition of complete and accurate diagnoses, procedures performed, and the treatment provided. The core of the program uses highly trained staff members to perform a concurrent inpatient review of the record. This allows the record to be coded post discharge in a timely and accurate manner. A highly successful CDI program is based on a highly interactive process between physicians, CDIS staff and other support services. The program does not challenge the provider’s medical judgement, but rather provides a methodology in which to clarify existing documentation. Acts as a liaison between the clinical and coding functions. Provides education to the medical staff and other clinical professional on documentation relevant to the Revenue Management processes and Discharge Not Final Billed reduction. Provides daily interactions with physicians and clinical professionals regarding documentation clarification and optimization. It is expected that the CDIS have previous clinical skills, including an understanding of Anatomy and Physiology in order to appropriately discuss with the physician such issues as the underlying etiology, principal diagnosis, diagnostic studies, treatment modalities, to name a few. The essential focus of this position is to analyze the clinical information, using the documentation as the primary driver for overall System Case Mix Index.

Job Duties

• Reviews inpatient medical records within 24-48 hours of admission for a specified patient population toevaluate documentation to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness; and initiate documentation of the review.
• Pursues a subsequent review of records every 3 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.

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

Hours: 40 hours per week; Dayshift

Weekends: None

Major Holidays: None

On-Call: None

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

Note: this position is not a remote position

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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. To learn more: https://jobs.geisinger.org/diversity

• 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
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.