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

Location: Work from home (Pennsylvania)

Shift: Days (United States of America)

Scheduled Weekly

Hours:

40

Worker Type: Regular

Exemption Status: Yes

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.

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. The position 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.

We offer a comprehensive benefits package starting on day one, including:

• Health, dental, and vision insurance
• Three medical plan choices
  , including expanded network options
• Pre-tax savings plans (FSA & HSA)
• Company-paid life, short-term, and long-term disability insurance
• 401(k) with automatic Geisinger contributions
• Generous PTO that accrues quickly
• Up to $5,000 in tuition reimbursement per calendar year
• MyHealth Rewards wellness program with financial incentives
• Family-friendly support
  : adoption/fertility assistance, parental leave, military leave, and  membership
• Employee Assistance Program (EAP): mental health, legal guidance, childcare/eldercare referrals, and more
• Voluntary benefits
  : accident, critical illness, hospital indemnity, identity theft protection, pet insurance, and more

The Senior CDI Specialist improves 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. Assists the providers with accurately identifying and documenting the healthcare services provided to the patient. The position will, through ongoing education, support the improvement and continue to sustain clinical documentation related to relative patient acuity, risk reduction, ad overall improvement and accuracy of Case Mix Index.

Acts as documentation liaison to physician staff as a means of finalizing information in the medical record.

• Reviews inpatient medical records within 24-48 hours of admission for a specified patient population to: evaluate the…