RN - Clinical Documentation Specialist - Part Time

York, PA | Nursing | Tracking Code: 65945

Job Description:

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

Essential 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.
 

NonEssential Accountabilities:

  1. Prepares and presents data analysis as required.
  2. Assists with special projects and attends meetings as needed.
  3. Performs other related duties as identified.
 

Common Expectations:

  1. Prepares and maintains appropriate documentation as required.
  2. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
  3. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovationThe following are nonessential job accountabilities for purposes:
 

Qualifications

  • Notes:
    • Other combinations of formal education, training and experience may be considered.
  • Minimum Experience:
    • 5 years recent hospital experience with ICU experience; Case management preferred.
    • Min Field of ExpertiseClinical Nurse II for internal applicants
  • Minimum Education:
    • Bachelor’s Degree
  • Required Certification:
    • Registration and current RN license in PA
  • Physical Demands:
    • Mostly sedentary work
    • Occasional prolonged standing/walking
  • Skills:
    • Organized, analytical, self-directed with critical thinking, problem solving and deductive reasoning skills; computer skills; experience with PowerPoint and Microsoft Office
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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

Welcome. Respect. Value.

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

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)