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Clinical Documentation Specialist
DLP Conemaugh Health System

Location: Johnstown, Pennsylvania
Work Setting: Hospital
Job Function:
CDI Specialist
Job Type:
Salary Range: $26.12 to $33.35


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

1) 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.
2) Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, policies and procedures.
3) Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes.
4) Manages assignment in CDI software and EMR.
5) Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
6) Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
7) Reviews clinical issues with coding staff to assign a working DRG.
8) Assists with special projects as needed.
9) 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


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.

Apply Online:

Posted: April 23, 2021 at 11:52 AM
Post ID: 60326

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