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Geisinger Health System Clinical Documentation Improvement Specialist; Registered Nurse in CAMP HILL, Pennsylvania

JOB TITLE: Clinical Documentation Improvement Specialist; Registered Nurse

LOCATION: Geisinger Holy Spirit



WORK TYPE: Full Time


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 Specialist (CDIS) is to assist the providers with accurately identifying and documenting the healthcare services provided to the patient. This is accomplished with the recognition of complete and accurate diagnoses, procedures performed, and the treatment provided. The core of the program uses highly trained staff members to perform a concurrent inpatient review of the record. This allows the record to be coded post discharge in a timely and accurate manner. A highly successful CDI program is based on a highly interactive process between physicians, CDIS staff and other support services. The program does not challenge the provider’s medical judgement, but rather provides a methodology in which to clarify existing documentation. Acts as a liaison between the clinical and coding functions.

Provides education to the medical staff and other clinical professional on documentation relevant to the Revenue Management processes and Discharge Not Final Billed reduction. Provides daily interactions with physicians and clinical professionals regarding documentation clarification and optimization.

It is expected that the CDIS have previous clinical skills, including an understanding of Anatomy and Physiology in order to appropriately discuss with the physician such issues as the underlying etiology, principal diagnosis, diagnostic studies, treatment modalities, to name a few.

The essential focus of this position is to analyze the clinical information, using the documentation as the primary driver for overall GHS Case Mix Index. The position will, through ongoing education, support the improvement and continue to sustain clinical documentation related to relative patient acuity, risk reduction, ad overall improvement and accuracy of Case Mix Index. Further, this position will act as documentation liaison to physician staff as a means of finalizing information in the medical record.


*1. Reviews inpatient medical records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness; and (b) initiate documentation of the review using nThrive CDI manager work sheet.

*2. Pursues a subsequent review of records every 2-3 days to support and assign a working DRG assignment upon discharge.

*3. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation.

*4.Attends physician rounds on assigned units, as well as Interdisciplinary Team meetings as appropriate to daily patient assignment.

*5. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient’s record.

*6. Collaborates with nursing staff, nutrition, pharmacist, along with the physicians on documentation and to resolve queries prior to the patient’s discharge.

*7. Consistently meets established productivity targets for record review.

*8. Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.

*9. Maintains a positive rapport with colleagues and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution.

*10.Maintains the confidentiality of all information acquired, pertaining to the patient, physician, associates, and visitors to Geisinger.

*11. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement.

*12. Promotes a partnership with the inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality.

*13. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient.

*14. Reports any existing or potential problem to the CDI Director.

*15. Complies with established hospital/Department Policies, Procedures

  1. Performs other duties as required or assigned for which the employee is qualified to perform.

*Denotes the essential functions of the job.


Demonstrates a level of knowledge about HIM Standards of coding and applies to ongoing evaluation of medical record documentation.

Demonstrates strong interpersonal skills and develop relationship with physicians and medical staff.

Demonstrates excellent communication skills.

Demonstrates ability to multitask efficiently and effectively.

Demonstrates clinical knowledge (Anatomy, Physiology, Pathophysiology, Pharmacology).

Demonstrates strong understanding of clinical, HIM, quality and Case Management workflow.


Current PA RN license in good standing required; BS-Nursing preferred. CDIP/CDIS preferred.

Minimum three years of acute care experience required.

Knowledge of coding concepts and guidelines and clinical terminology preferred.

Experience facilitating physician education.


Work is typically performed in a clinical environment.

Walking and standing is 80% of work time

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

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.

GEISINGER HOLY SPIRIT is a strong and growing healthcare provider serving south-central Pennsylvania. Geisinger Holy Spirit includes its flagship Geisinger Holy Spirit Hospital, a 311-bed Joint Commission accredited acute care facility located in Camp Hill, Pennsylvania. Geisinger Holy Spirit employs more than 2,600 people and has more than 500 physicians and advanced practitioners on its hospital medical staff. Sponsored by the Sisters of Christian Charity, Geisinger Holy Spirit delivers patient-centered care guided by Catholic values and the Ethical and Religious Directives of Healthcare. Geisinger Holy Spirit provides a comprehensive array of both inpatient and outpatient services across the continuum of care, including acute care, home health, emergency medical services, physician practices, and a host of outpatient facilities located throughout south-central Pennsylvania.

About Geisinger

One of the nation’s most innovative health services organizations, Geisinger serves more than 1.5 million patients in Pennsylvania and New Jersey. The system includes 13 hospital campuses, a nearly 600,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. A physician-led organization, with approximately 32,000 employees and more than 1,800 employed physicians, Geisinger leverages an estimated $12.7 billion positive annual impact on the Pennsylvania and New Jersey economies. Repeatedly recognized nationally for integration, quality and service, Geisinger has a long-standing commitment to patient care, medical education, research and community service. For more information, visit geisinger.org or connect with us on Facebook at http://www.facebook.com/geisingerhealth , Instagram at https://www.instagram.com/geisingerhealth/ , LinkedIn and Twitter at http://www.twitter.com/geisingerhealth .

** Does not qualify for J-1 waiver. 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.

*Domestic partner benefits not applicable at Geisinger Holy Spirit.