The Clinical Documentation Improvement Program (CDI) 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. The role of the Clinical Documentation Improvement Educator is to provide one-on-one and classroom clinical documentation and coding education to Clinical Documentation Improvement Specialists, medical staff, mid-level providers, and other healthcare staff members. Remains accessible as a subject matter expert for CCHS regarding documentation, reimbursement, and data interpretation as it relates to inpatient records. Conducts the quality review of inpatient CDI cases, queries, assigned codes, and working DRGs. Participates in process improvement projects impacted by documentation. Collaborates and works closely with CDI Director and Leads from various platforms to identify specific areas and providers in need of education.
COMPETENCIES AND SKILLS:
Demonstrates a basic understanding of the MS-DRG system, CC/MCC’s, impact on quality, and CMI as well as ICD-10 coding systems and how the guidelines relate to Clinical Documentation Improvement.
Demonstrates competency in teaching/learning process.
Demonstrates extensive clinical knowledge and understanding of anatomy and physiology, pathophysiology; best demonstrated by clinical experience in a hospital setting.
Demonstrates excellent verbal and written communication.
Demonstrates strong leadership skills.
Demonstrates strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
Demonstrates interpersonal skills that promote teamwork.
Demonstrates flexibility in prioritization.
Demonstrates the ability to function in a stressful, fast paced environment.
Demonstrates computer literacy.
Demonstrates understanding of DRG assignments and metrics associated with the CDI program.
Demonstrates understanding of coding guidelines for compliance purposes.
EDUCATION AND/OR EXPERIENCE:
BS-Nursing required. Currently licensed to practice as a registered nurse by Pennsylvania Board of Nurse Examiners required.
Minimum of five years of clinical experience in acute care setting required. Preferred clinical background in ED, ICU/CCU, Case Management.
Minimum of six years of experience with clinical documentation improvement in an inpatient hospital setting as well as DRG coding.
Experience with education and strong understanding of the requirements for clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payers preferred.
Electronic medical record and chart review experience preferred.
CDIP/CDIS certification preferred.
WORKING CONDITIONS/PHYSICAL DEMANDS:
Work is typically performed in a clinical environment.
Walking and standing is 50% of work time.
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.
GEISINGER MEDICAL CENTER: (GMC), located Danville PA, the largest tertiary/quaternary care teaching hospital in the region, is licensed for 475 beds, including 89 pediatric beds in the Janet Weis Children’s Hospital.GMC, a Magnet Hospital, maintains the region’s only Level 1 Regional Resource Trauma Center with additional qualifications in pediatrics.GMC offers an array of highly specialized medical and surgical services, including neurosciences, cardiovascular services, transplantation, women’s health (in the Women’s Pavilion), oncology and orthopaedics.The Hospital for Advanced medicine serves as an integrated center for the most critical patients.Outpatient services are available on and off campus.
ABOUT GEISINGER: Geisinger is a physician-led health system comprised of approximately 30,000 employees, including nearly 1,600 employed physicians, 13 hospital campuses, two research centers, and a 583,000-member health plan Geisinger is nationally recognized for innovative practices and quality care. Geisinger serves more than 3 million people in central, south-central and northeast Pennsylvania and also in southern New Jersey with the addition of National Malcolm Baldridge Award recipient AtlantiCare, A member of Geisinger. In 2017, the Geisinger Commonwealth School of Medicine became the newest member of 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. For more information, visit www.geisinger.org, or connect with us on Facebook, Instagram, LinkedIn and Twitter.
** Does not qualify for J-1 waiver. 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.
*Domestic partner benefits not applicable at Geisinger Holy Spirit.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout 45 counties in central, south-central and northeastern Pennsylvania and in southern New Jersey. Our physician-led system is comprised of 32,000 employees, including 1,800 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.