Clinical Documentation Specialist (Princeton)

Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Summary:

• Working under the leadership and moderate supervision of the Corporate Manager of Clinical Documentation and in close concert with both the clinical care teams and the Corporate HIM teams, the Clinical Documentation Specialist will educate and utilize compliant questions and tools toward a complete, reflective record. They will also analyze trends and offer direction to primary care staff w regard to changes in coding practices and noted trends noted in team documentation requiring clarity and/or specification to reflect truth in diagnostic reflection.
• The Clinical Documentation Specialist will be responsible for supporting an organization-wide system for improving clinical documentation in the medical record by prompting physicians and other clinicians for complete and accurate documentation. The CD Specialist will utilize presentation, general instruction, and a compliant query discussion to instruct the clinical teams in appropriate documentation as suggested by CMS coding guidelines and to ensure that the clinical chart is the true and reflective document of the patient, their related prioritized diagnostic portrait, severity of illness, and treatment related.

Responsibilities:

• The CDS will facilitate appropriate, accurate and complete clinical documentation to support diagnosis and procedure coding, to ensure the appropriate level of severity is captured for all patients reviewed under the CDS program. Perform admission reviews of all assigned patients using clinical documentation guidelines and CMS coding guidelines to ensure that the documentation by the physician captures all diagnosis/conditions for the patient, as reflected by the documentation in the medical record. Tracks all cases reviewed, noting physician queries and responses. Enters the tracking information into the CDS tracking system. Demonstrates the ability to communicate effectively with Physicians, groups of Physicians, residents, and all other members of the care team both individually and in groups. Educates internal staff on clinical documentation guidelines. Develops and conducts ongoing CDMP education for new staff, including new clinical documentation specialists, coders, physicians, residents, nursing and allied health professionals.

Credentials:

• RHIA, RHIT and CSS certifications (Preferred)
• CCDS or CDIP certification (Preferred)

Education or Equivalent Experience:

• Bachelor's Degree required
• #+ years of Healthcare Experience required
• Master's Degree preferred
• Clinical experience with knowledge of Medicare reimbursement system and coding structure preferred

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.