Manager - Clinical Documentation Improvement - INTERNAL APPLICANTS ONLY

Gettysburg, PA | Nursing | Tracking Code: 62024

Position Summary:

This position will support the Health Information Management Team for WellSpan's West Region at Chambersburg Hospital, Waynesboro Hospital and Gettysburg Hospital


General Summary:


Under the general supervision of the Director-Health Information Management, oversees the performance of the Clinical Documentation Registered Nurses (CDRN). Facilitates improvement in overall quality, completeness and accuracy of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers and health information management coding staff to ensure the clinical documentation reflects the level of service rendered to patients and is complete and accurate.


Duties and Responsibilities:


1 Serves as a resource for organization regarding compliant documentation standards and guidelines.
2 Educates all internal customers on compliant documentation opportunities, as well as performance improvement methodologies.
3 Demonstrates knowledge of DRG payer issues, prospective payment systems, case mix analysis, coding guidelines as they pertain to CDI, documentation opportunities, clinical documentation requirements, quality review requirements and referral policies and procedures.
4 Ensures team members are capturing the accuracy and completeness of clinical information used for patient care, measuring and reporting physician and hospital outcomes including evidence based measures, and appropriate reimbursement.
5 Conducts trend analysis to identify patterns and variations in documentation practices and initiates corrective action for resolution of any problems with documentation practices.
6 Collaborates with Case Management, Quality and Patient Safety departments to maintain an accurate portrayal of organization reports that utilize physician documentation and codes.
7 Reviews clinical issues with coding staff to assign a working DRG and reconcile it against the final DRG.
8 Develops a collaborative team and facilitates team work among CDI and coding team members.

Required Skills


Bachelor's Degree in Nursing

Master’s Degree (Preferred) 

Clinical Documentation Improvement 

Registration and current RN license in PA

Certifications in RHIA, CCDS, CDIP (Preferred) 

Ability to travel to multiple work locations with WellSpan's West Region

Required Experience

Minimum Experience 3 - 5 years of Clinical Documentation Experience (includes acute care, CDI and supervisory experience)

Leadership of a Clinical Documentation Improvement Team (Preferred)  

Similar Opportunities

Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Know, Respect, Include

WellSpan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected and valued, while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Established in 1800, Adams County includes the borough of Gettysburg, Pennsylvania. Home to more than 100,000 residents, the town is a mecca for Civil War history buffs and visitors who come to tour the Gettysburg National Battlefield, Gettysburg National Military Park and see the annual Civil War reenactment.

Also located here is Gettysburg College, which has a strong academic reputation in liberal arts. The county is steeped in heritage, and offers a peaceful, country atmosphere, yet is a convenient drive to Washington, D.C., Baltimore, MD and Harrisburg, PA. The area's diversity attracts a lively local music scene, and his home to numerous restaurants and wineries, fresh-produce markets, a ski resort and more. Adams County residents can find local employment in healthcare, tourism, agriculture and manufacturing. (Patient population: 102,000)