RN-Clinical Documentation Nurse -location can be at Good Sam or York

Lebanon, PA | Professional | Tracking Code: 54420

Join us at an upcoming event:

This position is flexible and the candidate may sit in York or Lebanon

General Summary:

Under the general supervision of the Manager-Clinical Documentation Improvement, reviews medical record documentation to facilitate the accurate representation of the severity of illness, patient acuity and risk of mortality for a specified patient population. Obtains appropriate clinical documentation through extensive interaction with physicians, healthcare providers and Health Information Management (HIM) professionals. Actively participates in meetings and education of staff related to Clinical Documentation Improvement (CDI).

Duties and Responsibilities:

The following are essential job accountabilities:

1 Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients by completing accurate and timely record reviews.

2 Improves the overall quality and completeness of clinical documentation by performing admission and continued stay reviews.

3 Demonstrates knowledge of Diagnosis Related Group (DRG) payer issues, documentation opportunities, and clinical documentation requirements.

4 Demonstrates knowledge of Medicare, general understanding of hospital based quality initiatives, and regulatory environment.

5 Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.

6 Completes timely follow up on all cases, especially those with clinical documentation clarifications and ensures points of clarification have been recorded in the patients’ medical record.

7 Formulates ethical and clinically credible documentation clarifications.

8 Processes discharges by updating the CDI software to reflect any changes in status, procedures and treatments, and confers with clinicians to finalize diagnoses.

9 Accurately inputs data into the CDI software.

10 Effectively and appropriately communicates with physicians and healthcare providers.

11 Reviews clinical issues with coding staff to assign a working DRG and reconcile final DRG.

12 Serves as a member of the CDI Task Force.

13 Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

14 Prepares educational materials for presentation at meetings, physician grand rounds, interdisciplinary rounds, physician staff meetings, and participates in new provider orientations.

Required Skills

RN license in Pennsylvania 

BSN required 

Ability to facilitate the improvement of overall quality, completeness and accuracy of medical record documentation which requires the candidate to be organized, analytical, self-directed with critical thinking, problem solving and deductive reasoning skills.

If internal must be at a Clinical Nurse II position for interview consideration 

CCDS certification preferred


Required Experience

At least 5 years of recent acute care experience with a critical care background.

Previous Case management experience preferred


Quality of Life

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization is comprised of a multispecialty medical group of more than 1,200 physicians and advanced practice clinicians, a regional behavioral health organization, a home care organization, six respected hospitals, more than 15,000 employees, and 140 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.

Quality of Life
Quality of Life

Formed in 1813, Lebanon is a quaint city of 25,700 residents. The area, rich in heritage and the small-town charm of yesteryear, features sites on the National Register of Historic Places, museums, scenic parks and recreation facilities, performing arts theaters, artists' studios, a farmers' market and dining establishments for all tastes.

Life in Lebanon County offers affordable housing and options for pursuing higher education. Residents can find local employment in manufacturing, retail, arts and entertainment, healthcare and service sectors. Located in southcentral Pennsylvania, Lebanon is within an easy driving distance to Harrisburg, Lancaster, Reading and York. (Patient population: 140,000)

Equal Opportunity Employment

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.

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