Tower Health

  • Clinical Documentation Specialist

    Job Locations US-PA-Phoenixville
    Requisition ID
    2018-17096
    Hospital
    Phoenixville Hospital
    Shift
    Day shift
    Department
    Health Information Manage
    Category (Portal Searching)
    Nursing/Patient Care
    # of Openings
    2
  • 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

    Options

    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed