RN - Clinical Documentation Specialist Registered Nurse

Location:

Geisinger Wyoming Valley (GWV)

Shift:

Days (United States of America)

Scheduled Weekly Hours:

40

Worker Type:

Regular

Exemption Status:

Yes

Job Summary:

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 professional 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 toevaluate documentation to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness; and initiate documentation of the review.
• Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge.
• Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation.
• 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 nursing staff, nutrition, pharmacist, along with the physicians on documentation and to resolve queries prior to the patient's discharge.
• Consistently meets established productivity targets for record review.
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
• Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement.
• Promotes a partnership with the inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality.
• 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.

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.

Position Details:

Hours: Typical hours are Monday through Friday: Day Shift

Weekends: Occasional- will be discussed during interview

Travel: None

Education and Experience: 3 years RN work experience is required; BSN is strongly preferred; Prior coding or CDI certification is preferred.

Note: this position is not a remote position

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