Clinical Documentation Improvement Specialist Senior RN

2 days ago


Danville, Pennsylvania, United States Geisinger Health System Full time
Job Summary

The Clinical Documentation Improvement Program at Geisinger Health System is designed to enhance the accuracy and completeness of physician documentation in patient medical records. As a Senior Clinical Documentation Improvement Specialist RN, you will play a crucial role in ensuring that healthcare services provided to patients are accurately documented and reflected in the medical record.

Key Responsibilities
  • Review inpatient medical records within 24 to 48 hours of admission to evaluate documentation and assign principal diagnosis, relevant secondary diagnoses, and procedures for accurate assignment, risk of mortality, and severity of illness.
  • Pursue subsequent reviews of records every three days to support and assign a working DRG assignment upon discharge.
  • Formulate queries when missing, conflicting, or unclear documentation is identified.
  • Provide ongoing education to physicians and healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in patient records.
  • Collaborate with nursing staff, nutrition, pharmacists, and physicians to resolve queries prior to patient discharge.
  • Consistently meet established productivity targets for record review.
  • Identify strategies for sustained work process changes that facilitate complete and accurate clinical documentation.
  • Participate in the analysis and trending of statistical data for specified patient populations and identify opportunities for improvement.
  • Promote a partnership with inpatient coding professionals to ensure accuracy of principal diagnosis, procedures, and completeness of supporting documentation.
Requirements
  • Minimum of 3 years of RN work experience.
  • BSN preferred.
  • Basic Life Support Certification, Clinical Documentation Improvement Practitioner, Certified Clinical Documentation Specialist, and Licensed Registered Nurse (Pennsylvania) certifications required.
What We Offer

Geisinger Health System offers a competitive compensation and benefits package, including full benefits starting on day one, three medical plan choices, pre-tax savings plans, company-paid life insurance, short-term disability, and long-term disability coverage, 401(k) plan with automatic Geisinger contributions, generous paid time off, up to $5,000 in tuition reimbursement per calendar year, and more.



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