RN - Registered Nurse - Senior Clinical Documentation Improvement Specialist
New
Work from home (Pennsylvania)Full-TimeSenior
Salary not disclosed
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Job Details
- Experience
- 3 years RN work experience
Requirements
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification
- Registered Nurse license in Pennsylvania or a Multistate License
- Minimum of 3 years RN work experience
- Bachelor's Degree in Nursing (preferred)
- Communication skills
- Computer Literacy
- Medical Records Management
- Medical Records Systems
- Teamwork skills
- Ability to Work Independently
- Certified Professional Coder - American Academy of Professional Coders (AAPC)
- Certified Risk Adjustment Coder - American Academy of Professional Coders (AAPC)
- Registered Health Information Technician (RHIT) - American Health Information Management Association
Responsibilities
- Reviews inpatient medical records within 24-48 hours of admission for a specified patient population to evaluate documentation for accurate DRG assignment, risk of mortality, and severity of illness.
- Formulates queries when missing, conflicting, or unclear documentation is identified.
- Attends physician rounds on assigned units and interdisciplinary team meetings.
- Provides on-going education to physicians and healthcare providers regarding clinical documentation improvement.
- Collaborates with nursing staff, clinical nutrition, and pharmacists to resolve queries prior to patient discharge.
- Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
- Maintains the confidentiality of all acquired information.
- Promotes a partnership with Inpatient Coding staff to provide clinical education and assure documentation accuracy.
- Acts as a resource person for the interdisciplinary team to promote collaboration and coordination of patient care.
- Assists the Director with daily organization of CDI workflow at all Geisinger facilities.
- Communicates and partners with the CDI Director regarding issues in need of a coordinated resolution.
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