Clinical Documentation Improvement Specialist Senior RN

4 days ago


Danville, Virginia, 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 documentation supports the appropriate severity of illness, expected risk of mortality, and complexity of care.

Key Responsibilities
  • Review inpatient medical records within 24-48 hours of admission to evaluate documentation and assign principal diagnosis, relevant secondary diagnoses, and procedures.
  • Pursue subsequent reviews 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 on clinical documentation improvement and the importance of accurate and complete documentation.
  • Collaborate with nursing staff, nutrition, pharmacists, and physicians to resolve queries and ensure accurate documentation.
  • Meet established productivity targets for record review and identify strategies for sustained work process changes.
  • 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 3 years of RN work experience.
  • BSN preferred.
  • Basic Life Support Certification, Certified Clinical Documentation Specialist, and Clinical Documentation Improvement Practitioner certifications required.
  • Strong analytical thinking, computer literacy, interpersonal communication, organizing, and problem management skills.
About Geisinger Health System

Geisinger Health System is committed to providing high-quality patient care, education, and research. We value diversity, inclusion, and collaboration, and strive to create a work environment that is safe, respectful, and supportive. If you are passionate about delivering exceptional patient care and improving healthcare outcomes, we encourage you to apply for this exciting opportunity.



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