Job Summary

​The Clinical Documentation Improvement Program (CDI) is designed to improve the physician's documentation in the patient's medical record supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. The role of the Clinical Documentation Improvement Manager and Educator is to plan, manage and coordinate CDI practices to ensure consistency, meet corporate compliance guidelines, and to ensure appropriate and effective reimbursement in cooperation with key departments. Provides education to physician, physician service lines as needed to support hospital operations ensuring accurate and complete medical record. Works with Medical Staff as needed. Educates clinical documentation nurses by providing one-on-one and classroom clinical documentation and coding education to Clinical Documentation Improvement Specialists on issues related to the government mandated Inpatient Perspective Payment Program (MS-DRGs) and works collaboratively with the coding Supervisors, medical staff, mid-level providers, and other healthcare staff members. Collaborates and works closely with CDI Director and Leads from various platforms to identify specific areas and providers in need of education.

Job Duties

• ​Self-directed with ability to manage multiple areas through collaboration. Manages and acts as a resource to the personnel assigned as direct reports.
• Develops clinical data reporting and uses analytical assessment of data, data manipulation, and professionally articulate data outcomes to improve operations and report to various committees, including but not limited to the Utilization Management and Revenue Cycle committees.  
• Plans, directs, educates, and assists with supervision of the CDI staff to ensure timely, accurate and complete processing of rendered services.
• Assumes responsibility for hiring, training and retention of employees.
• Establishes and monitors employee workflows, productivity, and quality. Evaluates staff performance.
• Develop and monitor internal key indicator metrics associated with CDI as it related to the revenue cycle and quality outcomes.
• Assists in setting annual department and individual performance goals for the upcoming year. Proactively review clinical documentation.
• Initiates recommendations for changes in classification, salary action, promotion, demotion, transfer, and termination.
• Assist with Interviews, selection and hiring of personnel.
• Effectively manages and oversees program performance regarding pertinent aspects of Revenue Cycle activity.
• Monitors and maintains an effective quality assurance and process improvement plan for clinical documentation processes. Plans and develops policies and procedures for system-wide CDI practices to meet Corporate Compliance guidelines and to ensure appropriate and effective reimbursement.
• Ensures overall integrity and exceptional performance of CDI staff through developed performance metric reporting.
• Ensures program knowledge and operational implementation of all related compliance, coding and documentation standards.
• Ensures program knowledge and operational implementation of teaching physician compliance guidelines and documentation standards as indicated by CMS and other contracts adopting these regulations.
• Develops and provides education on documentation opportunities and service line specific areas for improvement.
• Ensures quarterly periodic performance audits of staff to ensure compliance with all department policies and procedures.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Position Details

Experience: Minimum of 8 years RN work experience, plus 2 years managerial/supervisory experience is required. 5 years CDI experience is strongly preferred.

Certification: One of the following certifications is strongly preferred or obtained within 1 year of hire- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)

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Geisinger cares about not only its patients and members, but also about you and your family. We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally. We believe in creating a diverse and inclusive environment where all employees can be their authentic selves. To learn more: https://jobs.geisinger.org/diversity

• Full benefits (health, dental and vision) starting on day one
• Three medical plan choices, including an expanded network for out-of-area employees and dependents
• Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA)
• Company-paid life insurance, short-term disability, and long-term disability coverage
• 401(k) plan that includes automatic Geisinger contributions
• Generous paid time off (PTO) plan that allows you to accrue time quickly
• Up to $5,000 in tuition reimbursement per calendar year
• MyHealth Rewards wellness program to improve your health while earning a financial incentive
• Family-friendly support including adoption and fertility assistance, parental leave pay, military leave pay and a free Care.com membership with discounted backup care for your loved ones
• Employee Assistance Program (EAP): Referrals for childcare, eldercare, & pet care. Access free legal guidance, mental health visits, work-life support, digital self-help tools and more.
• Voluntary benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life and pet and legal insurance

Education

Graduate from Specialty Training Program- (Required), Bachelor's Degree-Nursing (Preferred)

Experience

Minimum of 8 years-Nursing (Required), Minimum of 2 years-Managerial/Supervisory (Required)

Certification(s) and License(s)

Basic Life Support Certification - Default Issuing Body; Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.

We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.

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