Job Description
- Description:
- Improves the physician’s documentation in the patient’s medical record
- Assists the providers with accurately identifying and documenting the healthcare services provided to the patient
- Acts as documentation liaison to physician staff as a means of finalizing information in the medical record
- Reviews inpatient medical records within 24-48 hours of admission for a specified patient population
- Formulates queries when it is determined there is missing, conflicting or unclear documentation
- Attends physician rounds on assigned units and interdisciplinary team meetings as appropriate
- Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement
- Collaborates with nursing staff and other healthcare providers on documentation to resolve queries prior to the patient’s discharge
- Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation
- Maintains confidentiality of all information acquired, pertaining to the patient, physician, associates, and visitors
- Promotes partnership with Inpatient Coding staff to assure documentation reflects the accuracy of the patient’s clinical status
- Communicates and partners with the CDI Director regarding issues in need of a coordinated resolution
- Requirements:
- Must currently hold one of the following certifications- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)
- Applicants must currently hold the required CDI certification in order to be considered for this position.
- Licensure: Must hold a Registered Nurse license in Pennsylvania or a Multistate License
- 3 years RN work experience is required; BSN is strongly preferred
- Benefits:
- 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
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