Top 29 Clinical documentation specialist Jobs in Harrisburg Pa

Clinical Documentation Integrity Specialist I
Wellspan Health —York, PA
- Full-time
- Nursing
- Microsoft Excel
- RN License
- Paid parental leave
- Health insurance
9d
Clinical Improvement Quality Specialist I
Wellspan Health —York, PA
- Full-time
- RN License
- Customer service
- Mid-level
- Paid parental leave
- Health insurance
12d
Clinical Informatics Specialist
UPMC —Harrisburg, PA
- $37.48 - $58.07 an hour
- Weekends as needed
- Nursing
- Hospital
- Physical & Rehabilitation Medicine
18h
Clinical Documentation Integrity Educator
Penn State Health —Hershey, PA
- 8 hour shift
- Hybrid work
- Background check
- Nursing
- RN License
- Paid parental leave
- Health insurance
Patient Access Documentation Coordinator - Practice Access
Penn State Health —Hershey, PA
- 8 hour shift
- Background check
- Medical office experience
- Mid-level
- Paid parental leave
- Health insurance
9d
Associate Clinical Research I - Emergency Medicine
Penn State Health —Hershey, PA
- PRN
- Background check
- Mid-level
- 3 years
- Paid parental leave
- Health insurance
9d
Medical Scribe - Float
Oak Street Health —York, PA
- $17.00 - $28.46 an hour
- Full-time
- Computer literacy
- HIPAA
- Clinic
- Health insurance
- Dental insurance
Regional RAI Specialist (Clinical Reimbursement)
Confidential Healthcare Facility —Harrisburg, PA
- $105,000 - $115,000 a year
- Full-time
- Skilled nursing facility
- RN License
- 5 years
- Travel reimbursement
- Opportunities for advancement
Quick Apply
Charge Nurse RN - Adult Psychiatric Inpatient - Days
Wellspan Health —York, PA
- Full-time
- Acute care
- Nursing
- Psychiatry
- Paid parental leave
- Health insurance
Medical Scribe
Oak Street Health —York, PA
- $17.00 - $28.46 an hour
- Full-time
- Computer literacy
- HIPAA
- Clinic
- Health insurance
- Dental insurance
Charge Nurse-RN - Adult Psychiatric Inpatient - Evenings
Wellspan Health —York, PA
- Full-time
- Acute care
- Nursing
- Psychiatry
- Paid parental leave
- Health insurance
Wound Care Specialist (RN) - Enterostomal Therapy (Harrisburg)
UPMC —Harrisburg, PA
- $34.92 - $54.16 an hour
- Weekends as needed
- CPR Certification
- Nursing
- Float pool
- Flexible schedule
5d
Wound Care Specialist (RN) - Hyperbaric Wound Therapy (West Shore)
UPMC —Mechanicsburg, PA
- $34.92 - $54.16 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
Professional Staff Nurse - Post Surgical Unit (Harrisburg Hospital)
UPMC —Harrisburg, PA
- $38.96 - $51.73 an hour
- Full-time
- CPR Certification
- Nursing
- Surgery
Clinic & Injection Room Nurse (LPN/RN)
Family Allergy & Asthma —York, PA
- PRN
- CPR Certification
- Nursing
- RN License
Quick Apply
2d
Professional Staff Nurse, Weekend Position - Post Surgical Unit (Harrisburg Hospital)
UPMC —Harrisburg, PA
- $38.96 - $51.73 an hour
- Full-time
- CPR Certification
- Nursing
- Surgery
- Paid holidays
- Loan repayment program
Clinical Documentation Specialist (Remote Part-Time Contract)
OnPoint Healthcare Solutions —United States
- $50 - $60 an hour
- Full-time
- Remote
- RN License
- 5 years
- Senior level
- Health insurance
- Dental insurance
Quick Apply
1d
Travel NICU RN
Fastaff —United States
- Up to $3,709 a week
- Travel nursing
- Background check
- Nursing
- Medication administration
- Health savings account
- Relocation assistance
Quick Apply
8d
Staff RN - ECMO Spec / FT, nights
Children's Nebraska —United States
- Overtime
- Nursing
- RN License
- BLS Certification
- Flexible schedule
Travel IMC RN Job in Birmingham, Alabama
GIFTED Healthcare —United States
- $2,122.06 a week
- Overtime
- Nursing
- Medication administration
- RN License
- Health insurance
- Dental insurance
Quick Apply

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Clinical Documentation Integrity Specialist I

Wellspan Health -
York, PA

Apply Now

Job Details

Full-time
9 days ago

Benefits

Paid parental leave
Health insurance
Paid time off
Parental leave
Retirement plan

Qualifications

Collaborate with healthcare professionals
Doctor of Medicine
Record keeping
Nursing
Microsoft Excel
Inpatient experience
RN License
Medical coding software
Medical software
Health education for healthcare providers
5 years
Nursing Diploma
Critical & intensive care
Mid-level
Acute care facility experience
Quality performance measurement
Clinical staff training
Nurse Practitioner (NP)
Task prioritization
Clinical training
Health information data integrity
Team training
Certified Registered Nurse Practitioner
Data reporting support
Health record chart audits
Medical record abstraction
Continuous clinical improvement initiatives
Document review
Doctor of Osteopathy
Medical License

Full Job Description

General Summary

Responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. Assists treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. Assesses clinical documentation through extensive review of the medical record, interaction with providers, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Duties and Responsibilities

Essential Functions:

Reviews medical records of hospitalized patients to identify the most appropriate principal diagnosis and to assign a working Diagnosis Related Group (DRG). Performs initial reviews, concurrent reviews, and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study. • Performs initial case reviews and appropriate number of follow-up reviews based on program standards. • Completes initial and follow-up medical record reviews using an organized approach to survey admit notes, past medical history, home meds, physician/provider documentation, treatments, orders, ancillary department notes, laboratory data, and other pertinent components of the clinical record. • Completes the initial review, pulling cases by prioritization. • Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
Using clinical insight and judgment, analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and appropriately queries the provider per guidelines. • Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, hospital acquired conditions (HAC), and patient safety indicators (PSI). • Follows each query through to closure including complete documentation of ongoing follow up activities and communication.
Maintains integrity and compliance in all chart reviews and queries.
Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
Develops and supports strong professional relationships with Clinical Documentation Integrity Specialists (CDS), coding staff, compliance, quality, and medical providers across the system.
Works collaboratively with medical, nursing, and ancillary staffs to improve the quality of chart documentation that assures appropriate DRG classification to accurately reflect patient severity of illness and risk of mortality and anticipated/geometric mean length of stay (GMLOS).
Demonstrates an understanding of complications, co-morbidities, severity of illness (SOI), risk of mortality (ROM), case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.
Provides CDI education to providers one on one, during staff meetings, or during department meetings.
Provides ongoing CDS team learning opportunities through sharing of professional knowledge.
Functions as a subject matter expert and actively participates in meetings as a problem-solver.
Facilitates and/or supports continuous improvement activities.
Supports and implements quality measures as identified by department manager.
Maintains professional competency by keeping abreast of new coding issues and guidelines.
Uses software systems (including APR-DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation.

Common Expectations:

Prepares and maintains appropriate documentation as required.
Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation
Prepares and presents data analysis as required.
Assists with special projects and attends meetings as needed.

Qualifications

Minimum Education:

Diploma Program in Nursing Required or
Associates Degree Required
Bachelors Degree Preferred

Work Experience:

5 years recent hospital experience with Critical Care experience (for RN without CDI experience) Required or
CDI experience as a concurrent or retrospective documentation specialist in an inpatient acute care facility. Required
Clinical Documentation Integrity experience. Preferred

Licenses:

Licensed Registered Nurse Upon Hire Required or
Registered Nurse Multi State License Upon Hire Required or
Licensed Medical Physician and Surgeon Upon Hire Required or
Licensed Doctor of Osteopathic Medicine Upon Hire Required or
Licensed Physician Assistant Upon Hire Required or
Certified Registered Nurse Practitioner Upon Hire Required
Certified Clinical Documentation Specialist Upon Hire Preferred or
Certified Document Integrity Practitioner Upon Hire Preferred

Courses and Training:

In lieu of the above Licenses and Certifications, a Medical Degree with experience as a concurrent or retrospective specialist in an inpatient acute care facility would be considered. Upon Hire Required
Certified Clinical Documentation Specialist Upon Hire Preferred or
Certified Document Integrity Practitioner Upon Hire Preferred

Knowledge, Skills, and Abilities:

Organized, analytical, self-directed with critical thinking, problem solving and deductive reasoning skills.
Computer skills.
Experience with PowerPoint, Excel and Microsoft Office.
Self-directed and motivated to function both independently and on teams.

Benefits Offered:

Comprehensive health benefits
Retirement savings plan
Paid time off (PTO)
Education assistance
Financial education and support, including DailyPay
Expanded Paid Parental Leave

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)

Apply Now

Refine Your Search

clinical documentation specialist jobs in harrisburg pa

Clinical Documentation Integrity Specialist I

Clinical Improvement Quality Specialist I

Clinical Informatics Specialist

Clinical Documentation Integrity Educator

Patient Access Documentation Coordinator - Practice Access

Associate Clinical Research I - Emergency Medicine

Medical Scribe - Float

Regional RAI Specialist (Clinical Reimbursement)

Charge Nurse RN - Adult Psychiatric Inpatient - Days

Medical Scribe

Charge Nurse-RN - Adult Psychiatric Inpatient - Evenings

Wound Care Specialist (RN) - Enterostomal Therapy (Harrisburg)

Wound Care Specialist (RN) - Hyperbaric Wound Therapy (West Shore)

Professional Staff Nurse - Post Surgical Unit (Harrisburg Hospital)

Clinic & Injection Room Nurse (LPN/RN)

Professional Staff Nurse, Weekend Position - Post Surgical Unit (Harrisburg Hospital)

Clinical Documentation Specialist (Remote Part-Time Contract)

Travel NICU RN

Staff RN - ECMO Spec / FT, nights

Travel IMC RN Job in Birmingham, Alabama

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