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Clinical Documentation Specialist Registered Nurse
2 months ago
The Clinical Documentation Improvement Program (CDI) at Geisinger Health is designed to enhance the accuracy and completeness of physician documentation in patient medical records. This program supports the appropriate severity of illness, expected risk of mortality, and complexity of care for patients. As a Clinical Documentation Improvement Specialist (CDIS), you will play a crucial role in assisting providers with accurately identifying and documenting healthcare services provided to patients. This involves recognizing complete and accurate diagnoses, procedures performed, and treatment provided.
Key Responsibilities- Concurrent Inpatient Record Review: Review inpatient medical records within 24-48 hours of admission for a specified patient population to evaluate documentation for accurate DRG assignment, risk of mortality, severity of illness, and initiate documentation of the review.
- Subsequent Record Review: Pursue a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge.
- Query Formulation: Formulate queries when it is determined there is missing documentation, conflicting documentation, or unclear documentation.
- Education and Training: Provide ongoing education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in patient records.
- Collaboration and Communication: Collaborate with nursing staff, nutrition, pharmacists, and physicians on documentation and to resolve queries prior to patient discharge.
- Productivity and Quality: Consistently meet established productivity targets for record review and identify strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
- Analysis and Trending: Participate in the analysis and trending of statistical data for specified patient populations, identify opportunities for improvement, and promote a partnership with inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures, and completeness of supporting documentation.
- Resource and Support: Act as a resource person for the interdisciplinary team to promote collaboration and coordination of patient care, considering age-specific, developmental, cultural, and spiritual needs of patients.
- Education: Graduate from a Specialty Training Program in Nursing (Required), Bachelor's Degree in Nursing (Preferred)
- Experience: Minimum of 3 years of Nursing experience (Required)
- Certification and License: Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania
- Skills: Communication, Medical Records Systems, Multitasking
