Clinical Documentation Improvement Specialist/RN

Penn State Health Milton S. Hershey Medical Center - Hershey, PA

The RN/Registered Nurse in this role is responsible for extensive collaboration with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded. The RN will also facilitate concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients. They will also conduct medical record audits to ensure that all services and assessments of the patient's condition were reported in accordance with the Uniform Hospital Discharge Data Set (UHDDS), Inpatient Prospective Payment System (IPPS), and Outpatient Prospective Payment System (OPPS) conventions. The Registered Nurse will provide education and expert guidance to physicians and coders regarding documentation & facility coding requirements as it relates to proper reimbursement and capture severity of illness and intensity of service via regular and ongoing training education programs.

Bachelor's Degree in Nursing or Master's Degree in Nursing required.
2 years acute care experience required.
Currently licensed to practice as a registered nurse by Pennsylvania Board of Nurse Examiners required.

Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.

Training and development background preferred.
Bachelor of Science Degree in Nursing preferred.

If chosen for this position, you may be required to pass a Post Offer Employment Physical Exam in accordance with the measurements listed in the Work Task Analysis (WTA) report. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. All individuals (including current employees) selected for a position will undergo a background check appropriate for the position's responsibilities.

Penn State Health is an equal opportunity, affirmative action employer, and is committed to providing employment opportunities to all qualified applicants without regard to race, color, religion, age, sex, sexual orientation, gender identity or expression, national origin, disability or protected veteran status. If you are unable to use our online application process due to an impairment or disability, please call 717-531-8440 between the hours of 8:30 AM and 4:30 PM, Eastern Standard Time, Monday – Friday, email or download our Accommodation Instructions for Job Applicants PDF for more detailed steps for assistance.

Union: Non Bargained