RN - Clinical Documentation Specialist - Day Shift

RN - Clinical Documentation Specialist - Day Shift

RN Senior Clinical Documentation Specialist. Day Shift (

Hours:

M-F 8 hours) Hybrid position with onsite requirements. No Weekends or Holidays.

Newark, DE — Christiana Care Hospital is hiring an RN Clinical Documentation Specialist to improve the overall quality and completeness of clinical documentation (CDI) within the inpatient medical record.

Ensure that health care services are administered with quality, cost efficiency, and within compliance, while improving and ensuring the overall quality, cost efficiency, and completeness of documentation within the inpatient medical record. Maintain accuracy of documented diagnosis and support clinical indicators. Facilitate modifications to clinical documentation through extensive concurrent interaction with Physician Advisor, physicians, coding staff, and other members of the healthcare team to support appropriate reimbursement and clinical severity captured compliantly for the level of service rendered to all patients.

Daily contact with Clinical Documentation Manager, HIMS/coding staff, and Physician Advisor. Frequent contact with physicians, physician office staff, clinical, and ancillary departmental staff, as well as HIM Coding Management.

• Concurrent review of inpatient medical records throughout the patient's hospitalization; analyze clinical status, current treatment, past medical history, and identify potential gaps in physician documentation.
• Communicate with physicians or other providers to validate diagnoses, clinical indicators, and appropriate prompts for documentation, if necessary, via verbal or written communication.
• Demonstrate proficient knowledge of HIMS standards of coding and apply it to ongoing evaluation of medical record documentation.
• Educate physicians and other key healthcare providers regarding best practice clinical documentation and the need for accurate and complete documentation in the health record.
• Review and clarify clinical issues in the health record with coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
• Monitor patient progress, consult with primary physician or designee, and other members of the care delivery team at agreed‑upon intervals or more frequently as needed.
• Participate in performance improvement activities related to documentation improvement.
• Maintain confidentiality of patients, members, and staff information.
• Attend coding/financial/CDI educational programs and regulatory educational programs, updating knowledge as necessary to maintain proficiency.
• Review all PSI encounters for completeness and accuracy; review outcomes with Physician Advisors and Medical Directors as needed.
• Attend daily huddles with HIMS to address any clinical concerns.
• Compute a working DRG to identify the anticipated length of stay and share with the care team for LOS goals.
• Use Vizient data to identify documentation opportunities and target physician education.
• Perform assigned work safely, adhering to established departmental safety rules and practices; report any unsafe activities, conditions, hazards, or safety violations in a timely manner.
• Perform other related duties as required.

• DE RN licensed or Compact State.
• Minimum of 3 years recent experience as a Registered Nurse in acute care; adult care setting preferred.
• RN experience in Cardiac, Critical Care, Med‑Surg, and Oncology highly desirable.
• Experience in Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding highly desirable.
• Certified Clinical Documentation Specialist (CCDS) required within one year of eligibility.

• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes.
• Knowledge of nursing principles, practices, and processes.
• Knowledge of ICD‑10 nomenclature, UHDDS, and general coding principles; knowledge of CMS, JCAHO, and external regulatory and quality requirements.
• Knowledge and ability to comply with the Health Insurance Portability and…