RN - Registered Nurse - Clinical Documentation Improvement Specialist

Job Overview

Location:

Geisinger Wyoming Valley (GWV) – Wilkes-Barre, Pennsylvania.

Shift: Days (United States of America).
Scheduled Weekly

Hours:

40.
Worker Type:
Regular.
Exemption Status:
Yes.

Job Summary: This on‑site Clinical Documentation Improvement Specialist (CDIS) supports inpatient physicians by ensuring accurate, complete documentation that drives correct diagnosis, procedures, and risk stratification in the medical record. The role performs concurrent inpatient reviews, collaborates with providers, and offers education to improve documentation quality and optimize revenue.

• Act as liaison between clinical and coding functions to ensure accurate DRG and risk adjustment.
• Review inpatient medical records within 24‑48 hours of admission to assign principal and secondary diagnoses, procedures, and risk/ severity categories.
• Conduct subsequent reviews every three days to finalize DRG, severity, and risk of mortality.
• Formulate queries for missing, conflicting, or unclear documentation and work with physicians and other providers to resolve them before discharge.
• Provide ongoing education and training to physicians and other clinical staff on documentation standards and CDI best practices.
• Collaborate with nursing, nutrition, pharmacy, and other interdisciplinary team members to clarify documentation and promote accurate record‑keeping.
• Identify and implement process improvements to enhance clinical documentation quality and compliance.
• Analyze and trend statistical data for the assigned patient population, identifying opportunities for improvement.
• Consistently meet productivity targets for record review and documentation optimization.
• Serve as a resource for interdisciplinary teams, promoting patient‑centered care and documentation accuracy.

• Registered Nurse (RN) licensed in Pennsylvania.
• Minimum of 3 years RN experience; BSN strongly preferred.
• Graduate from Specialty Training Program in Nursing (required) or equivalent;
  Bachelor’s Degree in Nursing (preferred).
• Strong clinical knowledge of anatomy and physiology.
• Proficiency with medical records systems and coding terminology.
• Excellent communication, multitasking, and collaboration skills.

• Health, dental, and vision insurance with three medical plan choices.
• Expanded network options and 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.

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.