RN Clinical Documentation Improvement Specialist - Clinical Doc Mgmt Program - FT

Shift: Day

Position Summary:

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through interaction with physicians, nursing staff, other patient caregivers, medical records coding staff to ensure that clinical documentation accurately reflects service rendered to patient. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Provides education to members of the health care team on an ongoing basis using diverse methodology.

Education, License & Cert:

BSN Bachelors Degree: RN; BSN required. Certification in area of specialty is required within 3 years. 3 or more years of CDI experience in an acute care setting along with current CCDS certification may substitute for BSN RN‐PA Registered Nurse ‐ PA: Current Pennsylvania State registered nurse license.

Experience:

Prior CDI experience preferred. Five years recent acute clinical experience in a hospital setting required. Critical care, utilization review or coding experience required. Requires excellent communication skills (both verbal and written), assessment/observation skills, demonstrated analytical thinking, and problem solving skills. Meets minimum score on pre‐hire competency test.

Essential Functions:

1. Facilitates modifications to clinical documentation for designated patients to ensure that documentation reflects the level of services rendered which supports proper coding, billing and reimbursement and quality of care outcomes.
2. Demonstrates knowledge of CDMP guidelines and program, DRG payor issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
3. Utilizes CDMP software/computer applications.
4. Facilitates teamwork and performance improvements in the organization.

Other Duties:

It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.

#LI-RB1

Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.

The Guthrie Clinic is an Equal Opportunity Employer.

The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.