COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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   Current UPMC employees must apply in HR Direct

Clinical Documentation Specialist

  • Job ID: 031161541
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours: Monday to Friday Days
  • Shift: Day Job
  • Facility: UPMC Pinnacle Hospitals
  • Department: Health Info-Admin-HBG
  • Location: 361 Alexander Spring Road, Carlisle PA 17015
  • Union Position: No
  • Salary Range: $29.66 to $45.96 / hour

Description

Purpose:
The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of services rendered to all inpatients.

Responsibilities:

  • Participating at the organizational level in clinical documentation improvement initiatives
  • Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear, or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
  • Preparing trended data for presentation one-on-one and small to medium groups of physicians
  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, 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
  • Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team
  • Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans.

Qualifications

  • Three years of previous clinical acute care registered nursing experience medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRG's; OR completion of Health Records Administration program (RHIA) or Accredited Record Technician (RHIT) AND 3 years of experience with the Prospective Payment System and DRG selection; OR specific knowledge as a consultant in Medical Record coding and DRG assignment required.
  • Prior Clinical Documentation Information work experience preferred.
  • Knowledge of computer technology, quality assurance activities, DRG, Quality Insights/Utilization review background is highly preferred.
  • Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required.

Licensure, Certifications, and Clearances:
Employees practicing in Maryland: Respiratory Therapist license may be used in substitution of the aforementioned certifications and licensure.

  • Certified Coding Specialist (CCS) OR Certified Registered Nurse Practitioner OR Doctor of Medicine (MD) OR Doctor of Podiatric Medicine OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT) OR Registered Nurse (RN)
  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

COVID-19 Vaccination Information

Individuals hired into this role must comply with UPMC’s COVID vaccination requirements upon beginning employment with UPMC. Refer to the COVID-19 Vaccination Information section at the top of this page to learn more.

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Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct

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