The Clinical Documentation Improvement Program 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. Assists the providers with accurately identifying and documenting the healthcare services provided to the patient. Analyzes the clinical information, using the documentation as the primary driver. Acts as documentation liaison to physician staff as a means of finalizing information in the medical record. Assists in the supervision of staff.
Provides concurrent review of the clinical documentation in the medical record.
Formulates queries via written and verbal communication when it is determined there is missing documentation, conflicting documentation or unclear documentation.
Performs a thorough chart review to identify and capture any secondary diagnosis, or complications within the concurrent tracking software for quality ratings and profiling purposes.
Serves as an operations coordinator for the team, in addition to performing the above regular duties within the job description.
Lead responsibilities would include: Assists with the scheduling of staff for appropriate coverage.
Assists with query reconciliation and DRG mismatches with clinical documentation and coding Provides feedback to Director on operational concerns.
Provides feedback to Physician Advisor on provider query performance.
Provides ongoing feedback to leadership.
Serves as a subject matter expert and authoritative resource on interpretation and application ofclinical documentation.
Participates in the training of all new CDI staff, including on-going mentorship.
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.
Graduate from Specialty Training Program-Nursing (Required), Bachelor's Degree-Nursing (Preferred)
Minimum of 6 years-Nursing (Required)
Certification(s) and License(s)
Basic Life Support Certification - Default Issuing Body; Certified Clinical Documentation Specialist - Default Issuing Body; Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania; Clinical Documentation Improvement Practitioner - Default Issuing Body
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 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.
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.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13... hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.