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Job Description

Job Title: Clinical Documentation Specialist - Community General(CGOH) - Harrisburg, PA
Job ID: 700686676
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Pinnacle Hospitals
Department: Health Infor-Coding-HBG
Location: 4300 Londonderry Road, Harrisburg PA 17109

Description

UPMC Pinnacle is currently hiring for a Clinical Documentation Specialist (CDS) for the Community General location in the Harrisburg, PA area. This position 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 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 CDI 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:
  • 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

    Salary Range: $28.44 to $44.07 / hour

    Union Position: No

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