Clinical Documentation Specialist

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We strongly encourage all candidates of diverse backgrounds and lived experiences to apply.

A Brief Overview
Under the general supervision of the Supervisor, Clinical Documentation Improvement, the Clinical Documentation Improvement Specialist (CDIS) facilitates and obtains appropriate physician documentation for any clinical conditions or procedures which support the appropriate severity of illness, expected risk of mortality and the complexity of care of the patient population. This individual exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and procedures for the pediatric patient population. This individual also educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing staff, and case management.

What you will do

• Essential Duties and Responsibilities:
• Completes initial and subsequent concurrent reviews of pediatric inpatient medical records in accordance with established timelines, in order to promote accurate code and DRG assignment and assessment of risk of mortality and severity of illness.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation in the health record when needed.
• Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation issues and strives to resolve physician queries prior to patient discharge.
• Reviews and clarifies clinical issues in the health record with the coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Supports and participates in the continuous assessment and improvement of the quality of services provided.
• Participates in the analysis and trending of statistical data for specific patient populations to identify opportunities for improvement
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership
• Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
• Other Responsibilities:
• Adheres to established departmental policies, procedures, and objectives.
• Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
• Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position.
• Demonstrates a courteous and professional manner through interactions with internal and external customers.
• Integrates scientific principles and research based knowledge in decision making.
• Exemplifies a professional image in appearance, manner and presentation.
• Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
• Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
• Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style
• Performs other related duties as assigned.

Education Qualifications

• Bachelor's Degree Nursing, Medicine, or Surgery Required

Experience Qualifications

• At least three (3) years Acute care nursing experience (e.g., ED, ICU, case management, etc.) Preferred
• At least three (3) years Acute care pediatric nursing experience (e.g., ED, ICU, case management, etc.) preferred will consider translatable adult acute care experience Preferred
• At least three (3) years of inpatient coding experience preferred

Skills and Abilities

• Ability to work effectively with all departments and all levels of CHOP professionals. (Required proficiency)
• Ability to work independently or within a team structure. (Required proficiency)
• Must be very organized and able to work independently. (Required proficiency)
• Ability to establish priorities among multiple needs, meet deadlines and maintain standards of productivity. (Required proficiency)
• Computer skills and a working knowledge of Word, Excel and Access. (Required proficiency)
• Strong knowledge base in complete and accurate clinical documentation in the acute care setting and for all healthcare disciplines. (Required proficiency)
• Strong knowledge base and experience in interpreting and applying federal/government regulations to ensure coding and documentation compliance (Required proficiency)
• Strong knowledge base of the conventions, rules and guidelines for multiple classification and reimbursement systems (i.e. ICD -10, DRGs, APR-DRGs, etc). (Required proficiency)
• Ability to establish rapport with physicians and other healthcare practitioners. (Required proficiency)
• Demonstrated knowledge of medical terminology, anatomy and physiology, pharmacology, computers, and encoding software. (Required proficiency)
• Demonstrated interpersonal, critical thinking, and time management skills. (Required proficiency)
• Strong communication, teaching and presentation skills; must be detail oriented, and possess good problem solving skills (Required proficiency)

Licenses and Certifications

• Registered Nurse (Pennsylvania) - Pennsylvania State Licensing Board - - Preferred or
• Registered Nurse (New Jersey) - New Jersey State Licensing Board - - Preferred or
• Clinical Documentation Improvement Practitioner (CDIP) - American Health Information Management Association - - Preferred or
• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Integrity Specialists (ACDIS) - - Preferred

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must be fully vaccinated against COVID-19 and receive an annual influenza vaccine. Learn more.

Employees may request exemptions for valid religious and medical reasons. Start dates may be delayed until candidates are immunized or exemption requests are reviewed.

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