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

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 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.

Applicants must currently hold the required CDI certification in order to be considered for this position:
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP).

This is a work from home position. It is full-time, 40 hours weekly; dayshift Monday through Friday.

Candidates must hold a Registered Nurse license in Pennsylvania or a Multistate License. A minimum of 3 years RN work experience is required; BSN is strongly preferred.

• 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 ongoing 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 workflow at all Geisinger facilities.
• Communicates and partners with the CDI…