Tower Health

Clinical Documentation Specialist

US-PA-Phoenixville
Requisition ID
2017-16414
Phoenixville Hospital
Shift
Day shift
Department
Health Information Manage
Category (Portal Searching)
Nursing/Patient Care
# of Openings
1

Overview

 
The CDI Specialist provides concurrent review of clinical documentation in the medical record by a thorough chart review to identify severity, comorbidities, complications, working DRG’s and procedures.
The Clinical Documentation Specialist works collaboratively with the medical staff, providers and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality. 
The Clinical Documentation Specialist collaborates with physicians, physician extenders, nurses, case managers and Medical Record coders to identify principal diagnosis options, secondary diagnoses, procedures, assign working DRGs and identify educational opportunities.
The Clinical Documentation Specialist is able to identify and communicate areas of focus through report analysis

Responsibilities

 

  • Provides concurrent review of clinical documentation in the medical record
  • Performs a daily thorough chart review to identify severity, working DRGs, secondary diagnoses, procedures and complications
  • Collaborate with and queries the medical staff, providers and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality
  • Develop physician education on a quarterly basis

 

Qualifications

 

Education:

  • Graduation from accredited Nursing School, BSN preferred
  • Current PA RN license

Experience/Knowledge/Skills:

  • Nationally Certified Clinical Documentation Specialist, preferred
  • Knowledge of clinical diagnoses
  • ICD-10 coding and DRG GMLOS/weight
  • Hospital acute care experience including Med/Surg and ICU
  • Organization and time management skills
  • Clinical analytical skills
  • Interpersonal and collaborative skills with ability to constructively share information with others

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