Clinical Documentation Integrity Specialist II - Day

Schedule 

Full Time: 40 Hours/Week

Hours: 8am - 4:30pm

This is a remote position where the ideal candidate would be located in South Central Pennsylvania or in Northern Maryland, but exceptional candidates located outside of the service area may be considered.

Occasional travel required within WellSpan’s geographic footprint.

General Summary

Responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. Assists treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. Assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Duties and Responsibilities

Essential Functions:

• Performs second level reviews and audits for CDI quality and accuracy (Mortality, HAC, PSI, denials, etc.).
• Responsible for ensuring efficiency and productivity of the processes and workflows of the team. Expert in workflow management and serves as a resource to staff.
• Reviews and provides input on policies and standard work.
• Identifies quality of care issues in documentation and seeks resolution of issues through appropriate channels.
• Serves as a subject matter expert and mentor for the CDI team and supports new hires during and after the orientation period.
• Educates Clinical Documentation Specialist (CDS) staff regarding opportunities for diagnosis clarification, principal diagnosis accuracy and improvement of capture of additional comorbid conditions to include HACs and focused PSI diagnoses.
• Focuses on specific documentation opportunities and projects identified by leadership and others within the organization to be impacted by documentation.
• Facilitates CDI education to physicians and clinicians by creating timely presentations that can be shared by CDS, while minimizing the non-productive time of the team.
• Initiates CDI projects for process improvement.
• Assists in other monitoring activities, special department projects, or other needs as determined by the department manager.
• Works independently most of the time with a high degree of autonomy.
• Flexible in work assignments.
• Demonstrates proficiency of the Clinical Documentation Integrity Specialist I role.

Common Expectations:

• Prepares and maintains appropriate documentation as required.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Prepares and presents data analysis as required.

Qualifications

Minimum Education:

• Bachelors Degree Required

Work Experience:

• 2 years Recent Clinical Documentation Integrity experience as a concurrent or retrospective documentation specialist in an inpatient acute care facility. Required

Licenses:

• Licensed Registered Nurse Upon Hire Required or
• Registered Nurse Multi State License Upon Hire Required or
• Licensed Medical Physician and Surgeon Upon Hire Required or
• Licensed Doctor of Osteopathic Medicine Upon Hire Required or
• Licensed Physician Assistant Upon Hire Required or
• Certified Registered Nurse Practitioner Upon Hire Required and
• Certified Clinical Documentation Specialist Upon Hire Required or
• Certified Document Integrity Practitioner Upon Hire Required

Courses and Training:

• In lieu of the above Licenses and Certifications, a Medical Degree with experience as a concurrent or retrospective specialist in an inpatient acute care facility would be considered. Upon Hire Required and
• Certified Clinical Documentation Specialist Upon Hire Required or
• Certified Document Integrity Practitioner Upon Hire Required

Knowledge, Skills, and Abilities:

• Organized, analytical, self-directed with critical thinking, problem solving and deductive reasoning skills.
• Computer skills.
• Experience with PowerPoint, Excel, and Microsoft Office.

Benefits Offered (click here for more details):

• Comprehensive health benefits
• Flexible spending and health savings accounts
• Retirement savings plan
• Paid time off (PTO)
• Short-term disability
• Education assistance
• Financial education and support, including DailyPay
• Wellness and Wellbeing programs
• Caregiver support via Wellthy
• Childcare referral service via Wellthy

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