RN, Registered Nurse – Clinical Documentation Improvement Specialist

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Serve as a bridge between clinical and coding operations.

• Train physicians, medical personnel, and clinical experts on documentation and Revenue Management procedures.

• Engage daily with physicians and clinical personnel to clarify and enhance documentation.

• Examine clinical data and documentation to support the System Case Mix Index.

• Review inpatient medical records within 24 to 48 hours of patient admission.

• Assign principal and secondary diagnoses, procedures, working DRG assignments, severity of illness, and risk of mortality.

• Conduct follow-up record reviews every three days until discharge.

• Develop queries for any missing, conflicting, or ambiguous documentation.

• Provide continuous education on clinical documentation improvement and the importance of accurate patient records.

• Collaborate with nursing teams, nutritionists, pharmacists, physicians, and inpatient coding professionals.

• Achieve set productivity goals for record reviews.

• Identify strategies for maintaining changes in work processes.

• Analyze and track statistical data to discover areas for improvement.

• Advocate for accurate principal diagnoses, procedures, supporting documentation, working and final DRG, severity of illness, and risk of mortality.

• Act as a resource for interdisciplinary collaboration and coordination of patient care.

⛳️ Requirements

• Minimum of three (3) years of experience as a Registered Nurse (RN).

• Graduate from a Specialty Training Program in Nursing (Required).

• Licensed Registered Nurse in Pennsylvania - RN_State of Pennsylvania.

• Bachelor of Science in Nursing (BSN) or equivalent strongly preferred.

• Proficient understanding of Anatomy and Physiology.

• Familiarity with clinical documentation, medical records, diagnoses, procedures, treatment modalities, and DRG assignment.

• Strong communication, medical records systems knowledge, and multitasking abilities.

• Availability to work during the day with a commitment of 40 scheduled hours per week.

🏝️ Benefits

• Health, dental, and vision insurance.

• Three options for medical plans, including expanded network choices.

• Pre-tax savings plans (FSA & HSA).

• Company-funded life, short-term, and long-term disability insurance.

• 401(k) plan with automatic contributions from Geisinger.

• Generous paid time off (PTO) that accumulates quickly.

• Up to $5,000 in tuition reimbursement available each calendar year.

• MyHealth Rewards wellness program offering financial incentives.

• Adoption and fertility assistance.

• Parental leave.

• Military leave.

• Membership to Care.com.

• Employee Assistance Program (EAP) providing mental health support, legal guidance, childcare/eldercare referrals, and more.

• Optional benefits such as accident, critical illness, hospital indemnity, identity theft protection, and pet insurance.

• Healthcare benefits available for full-time and part-time roles from day one.

• Benefits for domestic partners.

• Opportunities for professional development and quality improvement.

• Full-time schedule of 40 hours per week.