SHIFT:
Day (United States of America)
Seeking Breakthrough Makers
Children's Hospital of Philadelphia (CHOP) offers countless ways to change lives. Our diverse community of more than 20,000 Breakthrough Makers will inspire you to pursue passions, develop expertise, and drive innovation.
At CHOP, your experience is valued; your voice is heard; and your contributions make a difference for patients and families. Join us as we build on our promise to advance pediatric care-and your career.
CHOP's Commitment to Diversity, Equity, and Inclusion
CHOP is committed to building an inclusive culture where employees feel a sense of belonging, connection, and community within their workplace. We are a team dedicated to fostering an environment that allows for all to be their authentic selves. We are focused on attracting, cultivating, and retaining diverse talent who can help us deliver on our mission to be a world leader in the advancement of healthcare for children.
We strongly encourage all candidates of diverse backgrounds and lived experiences to apply.
A Brief Overview
This RN position requires an Associate Degree in Nursing and 3 years of previous RN experience in an acute care setting. It is 40 hours a week and is hybrid. The Team prefers a candidate with previous Clinical Documentation Specialist experience. With this this position the candidate will need to have strong critical thinking skills, will need to be comfortable communicating with providers and completing presentations.
Under the general supervision of the Supervisor, Clinical Documentation Improvement the Clinical Documentation Improvement Specialist (CDIS) facilitates and obtains appropriate physician documentation for any clinical conditions or procedures which support the appropriate severity of illness, expected risk of mortality and the complexity of care of the patient population. This individual exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and procedures for the pediatric patient population. This individual also educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing staff, and case management.
What you will do
Essential Duties and Responsibilities:
1. Completes initial and subsequent concurrent reviews of pediatric inpatient medical records in accordance with established timelines, in order to promote accurate code and DRG assignment and assessment of risk of mortality and severity of illness.
2. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation in the health record when needed.
3. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation issues and strives to resolve physician queries prior to patient discharge.
4. Reviews and clarifies clinical issues in the health record with the coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
5. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
6. Supports and participates in the continuous assessment and improvement of the quality of services provided.
7. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement
8. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership
9. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
Other Responsibilities:
1. Adheres to established departmental policies, procedures, and objectives.
2. Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
3. Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
4. Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards apprpriate to this position.
5. Demonstrates a courteous and professional manner through interactions with internal and external customers.
6. Integrates scientific principles and research based knowledge in decision making.
7. Exemplifies a professional image in appearance, manner and presentation.
8. Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
9. Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
10. Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style
11. Performs other related duties as assigned.
Education Qualifications
Associate's Degree Nursing Required
Bachelor's Degree Nursing Preferred
Experience Qualifications
At least three (3) years acute care nursing experience (e.g., ED, ICU, case management, etc.) Required
At least three (3) years acute care pediatric nursing experience (e.g., ED, ICU, case management, etc.) preferred will consider translatable adult acute care experience Preferred or
a CDIS Preferred
Skills and Abilities
Ability to work effectively with all departments and all levels of CHOP professionals.
Ability to work independently or within a team structure.
Must be very organized and able to work independently.
Ability to establish priorities among multiple needs, meet deadlines and maintain standards of productivity.
Computer skills and a working knowledge of Word, Excel and Access.
Strong knowledge base in complete and accurate clinical documentation in the acute care setting and for all healthcare disciplines.
Strong knowledge base and experience in interpreting and applying federal/government regulations to ensure coding and documentation compliance
Strong knowledge base of the conventions, rules and guidelines for multiple classification and reimbursement systems (i.e. ICD -10, DRGs, APR-DRGs, etc).
Ability to establish rapport with physicians and other healthcare practitioners.
Demonstrated knowledge of medical terminology, anatomy and physiology, pharmacology, computers, and encoding software.
Demonstrated interpersonal, critical thinking, and time management skills.
Strong communication, teaching and presentation skills; must be detail oriented, and possess good problem solving skills
Licenses and Certifications
Registered Nurse (Pennsylvania) - Pennsylvania State Licensing Board - upon hire - Required or
Registered Nurse (New Jersey) - New Jersey State Licensing Board - upon hire - Required
To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must be fully vaccinated against COVID-19 and receive an annual influenza vaccine.
Learn more.
Employees may request exemptions for valid religious and medical reasons. Start dates may be delayed until candidates are immunized or exemption requests are reviewed.
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