RN - Registered Nurse - Senior Clinical Documentation Improvement Specialist (CCDS Certification is required)
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.
Success Profile
What makes a successful nurse at Geisinger? Check out the top traits we're looking for and see if you have the right mix.
- Collaborative
- Communicator
- Compassionate
- Problem-solver
- Team Player
- Trustworthy
Culture
Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. Our nurses treat each other with respect and compassion, embrace diversity and take time to connect and listen. We are led by five main values:
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Kindness
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Excellence
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Safety
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Learning
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Innovation
Geisinger nurses: in their own words
Hear from some members of our Geisinger team and how the fight against COVID-19 has affected them.
Our Geisinger Family
Growing up in the northeast, Geisinger has always had a reputation of being a leader in cutting edge medicine. Being part of their staff is both a privilege and honor. So far working as a RN, has been an incredible experience. The staff is knowledgeable and passionate about their field. They are always willing to help me further my education and skills.
RN, Telemetry Unit, GMC
I had a very positive experience as a student nurse during my clinical rotations and knew I wanted to join the nursing team at Geisinger Lewistown Hospital. As a new nurse everyone has been extremely helpful. My coworkers are dedicated to the success of the team and providing the best care possible for our patients.
RN, Orthopedic Oncology, GLH
I'm excited to take the lessons I've learned along my journey from bedside nurse to educator to leader and help position Geisinger's more than 6,500 nurses—in all positions, from LPNs to RNs to advanced practice nurses—for their own future successes.
Chief Nursing Executive, MSN, RN
Benefits
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Health and Wellness Programs
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Tuition Reimbursement
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Professional Development
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Maternity and Paternity Leave
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Collaboration
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Awards and Recognition
Responsibilities
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
Licensure: Must hold a Registered Nurse license in Pennsylvania or a Multistate License
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)
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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)
-; -Skills
Communication; Teamwork; Working Independently; Computer Literacy; Medical Records Management; Medical Records SystemsAbout Geisinger
Founded more than 100 years ago by Abigail Geisinger, the system now includes ten hospital campuses, a 550,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,700 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and Twitter.
Our Commitment to Diversity, Equity and Inclusion
Geisinger values who you are, where you are from, and where you are going. We seek out people of various backgrounds and cultures with unique abilities, non-traditional career paths and ambitious aspirations. 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. Read more about Our Commitment to Inclusive Recruiting.
Our Vision & Values
Everything we do is about making better health easier 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.
Our Benefits
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.
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