RN Senior Clinical Documentation Specialist

Day Shift (Hours: M-F 8 hours) Hybrid position with onsite requirements. No Weekends or Holidays!

Newark, DE

Christiana Care Hospital is hiring a RN Clinical Documentation Specialist for improving the overall quality and completeness of clinical documentation (CDI) within the inpatient medical record.

Primary Function: 

Responsible to ensure that health care services are administered with quality, cost efficiency, and within compliance, along with improving and ensuring the overall quality, cost efficiency and completeness of documentation within the inpatient medical record.  Ensure accuracy of documented diagnosis and support clinical indicators. Facilitate modifications to clinical documentation through extensive concurrent interaction with Physician Advisor, physicians, coding staff and other members of the healthcare team to support the appropriate reimbursement and clinical severity are captured compliantly for the level of service rendered to all patients.

Scope, Purpose, And Frequency of Contacts: 

Daily contact with Clinical Documentation Manager, HIMS/coding staff, Physician Advisor, and intradepartmental personnel. Frequent contact with physicians, physician's office staff, clinical, and ancillary departmental staff. Frequent contact with HIM Coding Management  

Principal Duties & Responsibilities:   

• Concurrent review of inpatient medical records throughout the patient’s hospitalization. Analyzes clinical status of patient, current treatment, past medical history and identifies potential gaps in physician documentation.  
• Communicate with physicians or other providers to validate diagnoses, clinical indicators and appropriate prompts for documentation, if necessary, either verbally or written.   
• Demonstrates proficient knowledge of HIMS standards of coding and applies to ongoing evaluation of the medical record documentation.  
• Educates physicians and other key healthcare providers regarding best practice clinical documentation and the need for accurate and complete documentation in the health record.  
• Reviews and clarify clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.  
• Monitors patients progress consults with primary physician or designee and other members of the care delivery team at agreed-upon intervals, or more frequently, as needed.  
• Participates in performance improvement activities regarding documentation improvement  
• Maintains confidentiality of patients/members and staff information.  
• Attends coding/financial/CDI educational programs and regulatory educational programs and updates as necessary to maintain a proficient knowledge base.  
• Reviews all PSI encounters for completeness and accuracy.  Review outcome with Physician Advisors, and Medical Directors, as needed.   
• Attends daily huddles with HIMS to address any clinical concerns  
• Computes a working DRG to identify the anticipated length of stay.  Shared with the care team for LOS goals.  
• Uses Vizient data to identify documentation opportunities and targeted physician education.  
•  Performs assigned work safely, adhering to established departmental safety rules and practices; reports to manager, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.  
• Performs other related duties as required

Education and Experience Requirements:

• DE RN licensed or Compact State.
• Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred.
• RN experience in Cardiac, Critical Care, Med-Surg, and Oncology experience highly desirable.
• Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding experience are highly desirable.
• Certified Clinical Documentation Specialist (CCDS) is required in a year after eligibility.

Knowledge, Skill, And Ability: 

• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes.
• Knowledge of nursing principles, practices, and processes.
• Knowledge of ICD-10 nomenclature, UHDDS and general coding principles. Knowledge of CMS, JCAHO and external regulatory and quality requirements.  
• Knowledge and ability to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)  
• Knowledge of Performance Improvement Principles.  
• Ability to work efficiently independently.  
• Ability to collaborate with clinicians and administrative staff. • Ability to utilize computer applications on various platforms.  
• Ability to manage multiple projects with constant shifts in priority.  
• Ability to plan and organize work assignments

Physical Demands:

Prolonged daily review of charts on computer screen

Working Conditions:

Nursing Unit Environment – no patient contact

Normal Office Environment.

Frequent deadline situations