RN - Registered Nurse - Senior Clinical Documentation Improvement Specialist - CCDS Certification

Clinical Documentation Improvement Specialist

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 professionals 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 to evaluate the documentation in order to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness.
• Formulates queries when it is determined there is missing documentation, conflicting documentation, or unclear documentation.
• Attends physician rounds on assigned units, as well as interdisciplinary team meetings as appropriate to daily patient assignment.
• 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 the nursing staff, clinical nutrition, pharmacist, along with the physicians on documentation in an attempt to resolve queries prior to the patient's discharge.
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
• Maintains the confidentiality of all information acquired, pertaining to the patient, physician, associates, and visitors to Geisinger.
• Promotes a partnership with the Inpatient Coding staff, to provide clinical education, to assure documentation of discharge diagnosis and any secondary diagnoses to reflect the accuracy of the patient's clinical status and care.
• 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.
• Complies with established hospital and Department Policies, Procedures Assists the Director with daily organization of CDI work flow at all Geisinger facilities.
• Communicates and partners with the CDI Director regarding issues in need of a coordinated resolution.

Position Details:

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.

Education: Bachelor's Degree-Healthcare Related Degree (Required)

Experience: Minimum of 3 years-Nursing (Required)

Certification(s) and License(s):

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. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.