RN - Registered Nurse - Clinical Documentation Improvement Specialist

Job Duties

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

Qualifications

• A minimum of 3 years RN work experience is required.
• Bachelor's Degree-Nursing is strongly preferred.

Benefits

• 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 Care.com 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