HIM Clinical Documentation Specialist
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). Use - for any list of duties/requirements/benefits, and
for prose. Do NOT repeat the job title as a heading. Do NOT put Job ID / requisition numbers as headings — fold minor metadata into a short
or drop it. Preserve ALL substantive information; do NOT invent or summarize away detail. Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. IMPORTANT: include a section ONLY when the posting has real, specific content for it — never emit a heading followed by filler/placeholder text (e.g. "commensurate with experience", "not specified", "N/A", "varies", "TBD") and never create Pay/Schedule/Benefits sections unless the posting actually states them. Prefer a few substantive sections over many thin ones.
We need to decide which sections to include: The posting includes Summary (could be "About the role" or "Summary"). Responsibilities: list of duties. Credentials: maybe "Qualifications" or "Requirements". Education or Equivalent Experience: could be part of qualifications. Benefits: there is a paragraph about benefits: "We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region." That's benefits content. Pay: not specified. Schedule: not specified. So we should not create Pay or Schedule sections.
We need to include sections only when there is real specific content. So we can have:
About the role
with summary paragraph.
Responsibilities
with - list of responsibilities.
Qualifications
maybe combine credentials, education/experience, etc. Could also have Requirements
. The instruction says we can use those headings. We need to decide which to use. Probably "Qualifications" for credentials and education/experience. Or "Requirements" for required certifications/licensure, education, experience. Let's see content:
Credentials: RHIA, RHIT, and CCS certifications are preferred. CCDS or CDIP is preferred. RN, NP, or PA licensure is required.
Education or Equivalent Experience: Bachelor's degree is required. 3+ years of healthcare experience is required. Master's degree is preferred. Clinical experience with knowledge of Medicare reimbursement system & coding structures is preferred.
Thus we can put under Qualifications: required and preferred items.
We could also have a separate "Skills" section for abilities like "Ability to interpret, adapt, and apply guidelines and procedures", etc. But we can incorporate into Qualifications.
We need to avoid thin sections. Perhaps combine all qualification-related info into one Qualifications section.
Benefits: we have a paragraph about benefits. So we can have Benefits
with describing benefits.
We must not include EEO boilerplate etc. Remove that.
Also need to include entity/department/location maybe as metadata in a short
. The instruction: fold minor metadata into a short
or drop it. So we can include a short paragraph at top: Entity: Corporate Department: Corp HIM CDI Location: Remote, based out of Penn Presbyterian Medical Center- 51 N 39th St. That's metadata. We'll put in a
maybe.
We must not repeat job title as heading. The job title is "Clinical Documentation Specialist". Not used as heading.
We must output only HTML fragment.
Let's construct:
Entity: Corporate Department: Corp HIM CDI Location: Remote, based out of Penn Presbyterian Medical Center- 51 N 39th St
Then About the role
... summary ...
Then Responsibilities
with each responsibility as - .
Then
Qualifications
maybe with for required and preferred? Could separate into required and preferred but that may be thin. Could just list all items as - with notes (required/preferred). That's okay.
Then
Benefits
... benefits paragraph ...
We must ensure we preserve all substantive information. Let's extract summary text:
"The Clinical Documentation Specialist will be responsible for supporting an organization-wide system for improving clinical documentation in the medical record by prompting physicians and other clinicians for complete and accurate documentation. The CD Specialist will utilize presentation, general instruction, and a compliant query discussion to instruct the clinical teams in appropriate documentation as suggested by CMS coding guidelines and to ensure that the clinical chart is the true and reflective document of the patient, their related prioritized diagnostic portrait, severity of illness, and treatment related. Working under the leadership and moderate supervision of the Corporate Manager of Clinical Documentation and in close concert with both the clinical care teams and the Corporate HIM teams, the Clinical Documentation Specialist will educate and utilize compliant questions and tools toward a complete, reflective record. They will also analyze trends and offer direction to primary care staff w regard to changes in coding practices and noted trends noted in team documentation requiring clarity and/or specification to reflect truth in diagnostic reflection."
We need to keep that as is.
Responsibilities list: Let's extract each bullet from the responsibilities paragraph:
- Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of CMS coding guidelines
- Provide clinical care teams with ongoing education and training on current trends in documentation and coding
- Collaborate with the Corporate Manager of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the Clinical Documentation department
- Enter clinical review data and related anticipated follow-up in EPIC PENN Chart to truthfully demonstrate current state discovered via chart review, discovery of qualities needing further provider clarification, abstraction of clinical indicators, and the assignment of Initial DRG and Working DRG
- Generate compliant queries and non-leading clinical conversation w regard to requesting further specification and/or diagnostic clarity and/or clinical diagnostic significance and severity
- Ensure that the concurrent inpatient clinical documentation accurately reflects severity of illness and intensity of service using the above noted compliant query system
- Ensure the present on admission (POA) status of clinical conditions/diagnoses are charted appropriately within defined regulatory timeframes
- Assign a working MS-DRG upon initial admission review, and communicate with Physician or designee requesting appropriate documentation
- Ongoing concurrent chart review, identification of complications and co-morbidities, collaboration with team regarding improving documentation
- Maintain strict HIPPA compliance and confidentiality in reference to all information reviewed and/or discussed
- Maintains responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation
- Proficient in negotiating complex systems to effect positive change
- Ability to interpret, adapt, and apply guidelines and procedures
- Ability to analyze complex clinical scenarios and apply critical thinking.
- Extensive knowledge of reimbursement systems
- Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding
- Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary
- Serve as a resource on DRG issues
- Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
- Other duties as assigned to support the unit, department, entity, and health system organization
We need to keep all.
Qualifications: Let's list:
Credentials: RHIA, RHIT, and CCS certifications are preferred. CCDS or CDIP is preferred. RN, NP, or PA licensure is required.
Education or Equivalent Experience: Bachelor's degree is required. 3+ years of healthcare experience is required. Master's degree is preferred. Clinical experience with knowledge of Medicare reimbursement system & coding structures is preferred.
We could also include "Ability to interpret, adapt, and apply guidelines and procedures" etc but those are already in responsibilities? Actually they appear after responsibilities as separate bullet points: "Proficient in negotiating complex systems to effect positive change Ability to interpret, adapt, and apply guidelines and procedures Ability to analyze complex clinical scenarios and apply critical thinking. Extensive knowledge of reimbursement systems Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary Serve as a resource on DRG issues". Those are more like skills/knowledge. Could be included under Qualifications as well.
We'll combine all qualification-like items into Qualifications section.
Benefits paragraph: "We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives."
We need to keep that.
Now ensure no boilerplate: Remove EEO paragraph at end. Also remove "Live Your Life's Work" maybe it's a tagline but not boilerplate? It's part of description but could be considered promotional. It's not EEO. Might keep? It's not required but it's substantive? It's a slogan. Might be okay to keep but it's not essential. The instruction: Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. "Live Your Life's Work" is not boilerplate; it's a tagline. Could keep as part of summary? It's after benefits paragraph. Might be considered part of benefits/mission. I'd keep it as part of benefits paragraph maybe. But we already have benefits paragraph; we could append that sentence.
Better to include it as part of benefits paragraph: after benefits sentence, add "Live Your Life's Work". Actually the original: "We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work". So we can keep all that as benefits paragraph.
Now construct HTML.
We need to ensure proper escaping? Not needed.
Let's write:
Entity: Corporate Department: Corp HIM CDI Location: Remote, based out of Penn Presbyterian Medical Center- 51 N 39th St
About the role
The Clinical Documentation Specialist will be responsible for supporting an organization-wide system for improving clinical documentation in the medical record by prompting physicians and other clinicians for complete and accurate documentation. The CD Specialist will utilize presentation, general instruction, and a compliant query discussion to instruct the clinical teams in appropriate documentation as suggested by CMS coding guidelines and to ensure that the clinical chart is the true and reflective document of the patient, their related prioritized diagnostic portrait, severity of illness, and treatment related. Working under the leadership and moderate supervision of the Corporate Manager of Clinical Documentation and in close concert with both the clinical care teams and the Corporate HIM teams, the Clinical Documentation Specialist will educate and utilize compliant questions and tools toward a complete, reflective record. They will also analyze trends and offer direction to primary care staff w regard to changes in coding practices and noted trends noted in team documentation requiring clarity and/or specification to reflect truth in diagnostic reflection.
Responsibilities
- Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of
for prose. Do NOT repeat the job title as a heading. Do NOT put Job ID / requisition numbers as headings — fold minor metadata into a short
or drop it. Preserve ALL substantive information; do NOT invent or summarize away detail. Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. IMPORTANT: include a section ONLY when the posting has real, specific content for it — never emit a heading followed by filler/placeholder text (e.g. "commensurate with experience", "not specified", "N/A", "varies", "TBD") and never create Pay/Schedule/Benefits sections unless the posting actually states them. Prefer a few substantive sections over many thin ones. We need to decide which sections to include: The posting includes Summary (could be "About the role" or "Summary"). Responsibilities: list of duties. Credentials: maybe "Qualifications" or "Requirements". Education or Equivalent Experience: could be part of qualifications. Benefits: there is a paragraph about benefits: "We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region." That's benefits content. Pay: not specified. Schedule: not specified. So we should not create Pay or Schedule sections. We need to include sections only when there is real specific content. So we can have:
About the role
with summary paragraph.Responsibilities
with- list of responsibilities.
Qualifications
maybe combine credentials, education/experience, etc. Could also haveRequirements
. The instruction says we can use those headings. We need to decide which to use. Probably "Qualifications" for credentials and education/experience. Or "Requirements" for required certifications/licensure, education, experience. Let's see content: Credentials: RHIA, RHIT, and CCS certifications are preferred. CCDS or CDIP is preferred. RN, NP, or PA licensure is required. Education or Equivalent Experience: Bachelor's degree is required. 3+ years of healthcare experience is required. Master's degree is preferred. Clinical experience with knowledge of Medicare reimbursement system & coding structures is preferred. Thus we can put under Qualifications: required and preferred items. We could also have a separate "Skills" section for abilities like "Ability to interpret, adapt, and apply guidelines and procedures", etc. But we can incorporate into Qualifications. We need to avoid thin sections. Perhaps combine all qualification-related info into one Qualifications section. Benefits: we have a paragraph about benefits. So we can haveBenefits
withdescribing benefits. We must not include EEO boilerplate etc. Remove that. Also need to include entity/department/location maybe as metadata in a short
. The instruction: fold minor metadata into a short
or drop it. So we can include a short paragraph at top: Entity: Corporate Department: Corp HIM CDI Location: Remote, based out of Penn Presbyterian Medical Center- 51 N 39th St. That's metadata. We'll put in a
maybe. We must not repeat job title as heading. The job title is "Clinical Documentation Specialist". Not used as heading. We must output only HTML fragment. Let's construct:
Entity: Corporate Department: Corp HIM CDI Location: Remote, based out of Penn Presbyterian Medical Center- 51 N 39th St
ThenAbout the role
... summary ...
ThenResponsibilities
- with each responsibility as
- .
Then
Qualifications
maybe with- for required and preferred? Could separate into required and preferred but that may be thin. Could just list all items as
- with notes (required/preferred). That's okay.
Then
Benefits
... benefits paragraph ...
We must ensure we preserve all substantive information. Let's extract summary text: "The Clinical Documentation Specialist will be responsible for supporting an organization-wide system for improving clinical documentation in the medical record by prompting physicians and other clinicians for complete and accurate documentation. The CD Specialist will utilize presentation, general instruction, and a compliant query discussion to instruct the clinical teams in appropriate documentation as suggested by CMS coding guidelines and to ensure that the clinical chart is the true and reflective document of the patient, their related prioritized diagnostic portrait, severity of illness, and treatment related. Working under the leadership and moderate supervision of the Corporate Manager of Clinical Documentation and in close concert with both the clinical care teams and the Corporate HIM teams, the Clinical Documentation Specialist will educate and utilize compliant questions and tools toward a complete, reflective record. They will also analyze trends and offer direction to primary care staff w regard to changes in coding practices and noted trends noted in team documentation requiring clarity and/or specification to reflect truth in diagnostic reflection." We need to keep that as is. Responsibilities list: Let's extract each bullet from the responsibilities paragraph: - Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of CMS coding guidelines - Provide clinical care teams with ongoing education and training on current trends in documentation and coding - Collaborate with the Corporate Manager of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the Clinical Documentation department - Enter clinical review data and related anticipated follow-up in EPIC PENN Chart to truthfully demonstrate current state discovered via chart review, discovery of qualities needing further provider clarification, abstraction of clinical indicators, and the assignment of Initial DRG and Working DRG - Generate compliant queries and non-leading clinical conversation w regard to requesting further specification and/or diagnostic clarity and/or clinical diagnostic significance and severity - Ensure that the concurrent inpatient clinical documentation accurately reflects severity of illness and intensity of service using the above noted compliant query system - Ensure the present on admission (POA) status of clinical conditions/diagnoses are charted appropriately within defined regulatory timeframes - Assign a working MS-DRG upon initial admission review, and communicate with Physician or designee requesting appropriate documentation - Ongoing concurrent chart review, identification of complications and co-morbidities, collaboration with team regarding improving documentation - Maintain strict HIPPA compliance and confidentiality in reference to all information reviewed and/or discussed - Maintains responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation - Proficient in negotiating complex systems to effect positive change - Ability to interpret, adapt, and apply guidelines and procedures - Ability to analyze complex clinical scenarios and apply critical thinking. - Extensive knowledge of reimbursement systems - Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding - Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary - Serve as a resource on DRG issues - Performs duties in accordance with Penn Medicine and entity values, policies, and procedures - Other duties as assigned to support the unit, department, entity, and health system organization We need to keep all. Qualifications: Let's list: Credentials: RHIA, RHIT, and CCS certifications are preferred. CCDS or CDIP is preferred. RN, NP, or PA licensure is required. Education or Equivalent Experience: Bachelor's degree is required. 3+ years of healthcare experience is required. Master's degree is preferred. Clinical experience with knowledge of Medicare reimbursement system & coding structures is preferred. We could also include "Ability to interpret, adapt, and apply guidelines and procedures" etc but those are already in responsibilities? Actually they appear after responsibilities as separate bullet points: "Proficient in negotiating complex systems to effect positive change Ability to interpret, adapt, and apply guidelines and procedures Ability to analyze complex clinical scenarios and apply critical thinking. Extensive knowledge of reimbursement systems Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary Serve as a resource on DRG issues". Those are more like skills/knowledge. Could be included under Qualifications as well. We'll combine all qualification-like items into Qualifications section. Benefits paragraph: "We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives." We need to keep that. Now ensure no boilerplate: Remove EEO paragraph at end. Also remove "Live Your Life's Work" maybe it's a tagline but not boilerplate? It's part of description but could be considered promotional. It's not EEO. Might keep? It's not required but it's substantive? It's a slogan. Might be okay to keep but it's not essential. The instruction: Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. "Live Your Life's Work" is not boilerplate; it's a tagline. Could keep as part of summary? It's after benefits paragraph. Might be considered part of benefits/mission. I'd keep it as part of benefits paragraph maybe. But we already have benefits paragraph; we could append that sentence. Better to include it as part of benefits paragraph: after benefits sentence, add "Live Your Life's Work". Actually the original: "We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work". So we can keep all that as benefits paragraph. Now construct HTML. We need to ensure proper escaping? Not needed. Let's write:Entity: Corporate Department: Corp HIM CDI Location: Remote, based out of Penn Presbyterian Medical Center- 51 N 39th St
About the role
The Clinical Documentation Specialist will be responsible for supporting an organization-wide system for improving clinical documentation in the medical record by prompting physicians and other clinicians for complete and accurate documentation. The CD Specialist will utilize presentation, general instruction, and a compliant query discussion to instruct the clinical teams in appropriate documentation as suggested by CMS coding guidelines and to ensure that the clinical chart is the true and reflective document of the patient, their related prioritized diagnostic portrait, severity of illness, and treatment related. Working under the leadership and moderate supervision of the Corporate Manager of Clinical Documentation and in close concert with both the clinical care teams and the Corporate HIM teams, the Clinical Documentation Specialist will educate and utilize compliant questions and tools toward a complete, reflective record. They will also analyze trends and offer direction to primary care staff w regard to changes in coding practices and noted trends noted in team documentation requiring clarity and/or specification to reflect truth in diagnostic reflection.
Responsibilities
- Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of
- with notes (required/preferred). That's okay.
Then
- .
Then