DLP Conemaugh Health System
Introduction:
Conemaugh Health System, a member of Duke LifePoint Healthcare, is the largest healthcare provider in west central Pennsylvania. Over a half-million patients are served each year through the Conemaugh Physician Group and Medical Staff, a network of hospitals, specialty clinics and patient focused programs. We are committed to excellence and our Mission of Making Communities Healthier.
Job Description:
Job Summary
- Responsible for improving overall quality, accuracy and completeness of clinical documentation.
- Facilitates accuracy of clinical documentation through extensive communication with Physicians, other Care Team Members, and Coding Staff.
- Assures all clinical documentation is appropriate for level of service provided to all patients.
- Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines and Life Point Hospital policy.
- Provides education to Care Team Members related to the clinical documentation process.
- Reviews clinical issues and identified query response concerns with physician advisors.
Mission Responsibilities:
- Core Competencies
- Contributes to achievement of our Mission and Vision of the organization:
- Adapting to Change – Responds to change with a positive attitude and a willingness to learn new ways to accomplish work activities and objectives.
- Continuous Improvement – Acts to constantly improve the level of clinical and non-clinical outcomes and level of customer satisfaction in both individual and team work processes.
- Customer Focus – Demonstrates concern for meeting or exceeding internal and external customer’s expectations/requirements in a manner that provides satisfaction for the customer.
- Teamwork – Accomplishes tasks through working effectively with others and appreciating the value and commitment of every member.
- Service Excellence – Strives toward achievement of the CARING Values.
Essential Responsibilities
- Facilitates accurate, complete clinical documentation to support the level of service rendered to all patients from admission to discharge through concurrent stay reviews utilizing Compliant Documentation Management Program (CDMP) guidelines.
- Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, policies and procedures.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes.
- Manages assignment in CDI software and EMR.
- Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
- Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
- Reviews clinical issues with coding staff to assign a working DRG.
- Assists with special projects as needed.
- Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10.
Other Responsibilities
All other responsibilities as assigned in accordance with qualifications
Required Qualifications:
- Five years’ experience in Med/Surg Nursing
- Current, valid PA Professional Nursing License .
- Demonstrates behaviors that support the CARING Values.
- Excellent communication skills, both verbal and written.
- Excellent computer skills
- Ability to be self-directed and independent.
- Strong interpersonal skills, team player, service excellence focused.
- Excellent time management
Preferred Qualifications:
Clinical Documentation Improvement experience
Critical Care experience
Certified Clinical Documentation Specialist CCDS
Education Qualifications:
High School Diploma or equivalent. Bachelor’s Degree in Nursing
Compensation/Benefits:
We offer excellent compensation and benefits packages including medical insurance and a 401k plan.
Instructions for Resume Submission:
We require an online application be completed.
