| JOB TITLE: Clinical Documentation Improvement Specialist, RN LOCATION: Geisinger Medical Center Main Campus WORK SCHEDULE: Days WORK TYPE: PART TIME (.5 FTE) 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 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 GHS Case Mix Index. 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. Further, this position will act as documentation liaison to physician staff as a means of finalizing information in the medical record. COMPETENCIES AND SKILLS: Demonstrates a level of knowledge about HIM Standards of coding and applies to ongoing evaluation of medical record documentation.
Demonstrates strong interpersonal skills and develop relationship with physicians and medical staff.
Demonstrates excellent communication skills.
Demonstrates ability to multitask efficiently and effectively.
Demonstrates clinical knowledge (Anatomy, Physiology, Pathophysiology, Pharmacology).
Demonstrates strong understanding of clinical, HIM, quality and Case Management workflow. EDUCATION AND/OR EXPERIENCE: Current PA RN license in good standing required; BS-Nursing preferred. CDIP/CDIS preferred.
Minimum three years of acute care experience required.
Knowledge of coding concepts and guidelines and clinical terminology preferred.
Experience facilitating physician education.
WORKING CONDITIONS/PHYSICAL DEMANDS: Work is typically performed in a clinical environment.
Walking and standing is 80% of work time.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. GEISINGER MEDICAL CENTER: (GMC), located Danville, Pa., the largest tertiary/quaternary care teaching hospital in the region, is licensed for 475 beds, including 89 pediatric beds in the Janet Weis Children’s Hospital. GMC, a Magnet Hospital, maintains the region’s only Level 1 Regional Resource Trauma Center with additional qualifications in pediatrics. GMC offers an array of highly specialized medical and surgical services, including neurosciences, cardiovascular services, transplantation, women’s health (in the Women’s Pavilion), oncology and orthopaedics. The Hospital for Advanced Medicine serves as an integrated center for the most critical patients. Outpatient services are available on and off campus. ABOUT GEISINGER: Geisinger is a physician-led health system comprised of approximately 30,000 employees, including nearly 1,600 employed physicians, 13 hospital campuses, two research centers, and a 583,000-member health plan Geisinger is nationally recognized for innovative practices and quality care. Geisinger serves more than 3 million people in central, south-central and northeast Pennsylvania and also in southern New Jersey with the addition of National Malcolm Baldridge Award recipient AtlantiCare, A member of Geisinger. In 2017, the Geisinger Commonwealth School of Medicine became the newest member of the Geisinger Family. We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. For more information, visit www.geisinger.org, or connect with us on Facebook, Instagram, LinkedIn and Twitter. ** Does not qualify for J-1 waiver. 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. *Domestic partner benefits not applicable at Geisinger Holy Spirit. | 
