Clinical Documentation Integrity Specialist - Full Time

  • Lebanon, PA
  • WellSpan Health
  • HIM-Clin Doc Integrity
  • Full Time - Day
  • Nursing
  • Req #: 68749
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Job Description


Under the general supervision of the Manager-Clinical Documentation Improvement, reviews medical record documentation to facilitate the accurate representation of the severity of illness, patient acuity and risk of mortality for a specified patient population. Obtains appropriate clinical documentation through extensive interaction with physicians, healthcare providers and Health Information Management (HIM) professionals. Actively participates in meetings and education of staff related to Clinical Documentation Improvement (CDI).


Duties and Responsibilities


  1. Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients by completing accurate and timely record reviews.
  2. Improves the overall quality and completeness of clinical documentation by performing admission and continued stay reviews.
  3. Demonstrates knowledge of Diagnosis Related Group (DRG) payer issues, documentation opportunities, and clinical documentation requirements.
  4. Demonstrates knowledge of Medicare, general understanding of hospital based quality initiatives, and regulatory environment.
  5. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
  6. Completes timely follow up on all cases, especially those with clinical documentation clarifications and ensures points of clarification have been recorded in the patients’ medical record.
  7. Formulates ethical and clinically credible documentation clarifications.
  8. Processes discharges by updating the CDI software to reflect any changes in status, procedures and treatments, and confers with clinicians to finalize diagnoses.
  9. Accurately inputs data into the CDI software.
  10. Effectively and appropriately communicates with physicians and healthcare providers.
  11. Reviews clinical issues with coding staff to assign a working DRG and reconcile final DRG.
  12. Serves as a member of the CDI Task Force.
  13. Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
  14. Prepares educational materials for presentation at meetings, physician grand rounds, interdisciplinary rounds, physician staff meetings, and participates in new provider orientations..

Common Expectations


  1. Prepares and maintains appropriate documentation as required.
  2. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
  3. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovationThe following are nonessential job accountabilities for purposes:


  • Notes:
    • Other combinations of formal education, training and experience may be considered.
  • Minimum Experience:
    • 5 years recent hospital experience with ICU experience; Case management preferred.
    • Min Field of ExpertiseClinical Nurse II for internal applicants
  • Minimum Education:
    • Bachelor’s Degree
  • Required Certification:
    • Registration and current RN license in PA
  • Physical Demands:
    • Mostly sedentary work
    • Occasional prolonged standing/walking
  • Skills:
    • Organized, analytical, self-directed with critical thinking, problem solving and deductive reasoning skills; computer skills; experience with PowerPoint and Microsoft Office