Job Summary

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.

Job Duties

Reviews inpatient medical records within 24-48 hours of admission for a specified patient population to: evaluate the documentation in order to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation.

Attends physician rounds on assigned units, as well as interdisciplinary team meetings as appropriate to daily patient assignment.

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 the nursing staff, clinical nutrition, pharmacist, along with the physicians on documentation in an attempt to resolve queries prior to the patient’s discharge.

Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.

Maintains the confidentiality of all information acquired, pertaining to the patient, physician, associates, and visitors to Geisinger.

Promotes a partnership with the Inpatient Coding staff, to provide clinical education, to assure documentation of discharge diagnosis and any secondary diagnoses’ to reflect the accuracy of the patient’s clinical status and care.

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.

Complies with established hospital and Department Policies, Procedures Assists the Director with daily organization of CDI work flow at all Geisinger facilities.

Communicates and partners with the CDI Director regarding issues in need of a coordinated resolution.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Position Details

Applicants must currently hold the required CDI certification in order to be considered for this position.

Hours: 40 hours per week; Dayshift- Monday through Friday

Location: This is a work from home position.

Education and Experience: 3 years RN work experience is required; BSN is strongly preferred

Certification: Must currently hold one of the following certifications- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)

Geisinger cares about not only its patients and members, but also about you and your family. We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally. We believe in creating a diverse and inclusive environment where all employees can be their authentic selves. To learn more: https://jobs.geisinger.org/diversity

Full benefits (health, dental and vision) starting on day one

Three medical plan choices, including an expanded network for out-of-area employees and dependents

Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA)

Company-paid life insurance, short-term disability, and long-term disability coverage

401(k) plan that includes automatic Geisinger contributions

Generous paid time off (PTO) plan that allows you to accrue time quickly

Up to $5,000 in tuition reimbursement per calendar year

MyHealth Rewards wellness program to improve your health while earning a financial incentive

Family-friendly support including adoption and fertility assistance, parental leave pay, military leave pay and a free Care.com membership with discounted backup care for your loved ones

Employee Assistance Program (EAP): Referrals for childcare, eldercare, pet care. Access free legal guidance, mental health visits, work-life support, digital self-help tools and more.

Voluntary benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life and pet and legal insurance

Education

Bachelor's Degree-Healthcare Related Degree (Required)

Experience

Minimum of 3 years-Nursing (Required)

Certification(s) and License(s)

-; -

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. SAFETY: We provide a safe environment for our patients and members and 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. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.

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.