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Clinical Documentation Spec

Johnstown, Pennsylvania

Req ID 7479-9330 Post Date Dec. 10, 2024 CategoryProfessional - Clinical FacilityConemaugh Memorial Medical Center
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Conemaugh Memorial Medical Center

 

Who We Are:

People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Conemaugh Memorial Medical Center is the largest healthcare provider in west central Pennsylvania, serving over a half-million patients each year.  Conemaugh Memorial Medical Center has 537 inpatient, behavioral health, rehabilitation, and transitional care beds and is home to the highest level of care designations for Neonatal Care (Level 3) and Trauma Care (Level 1).

Where We Are:

The city of Johnstown is home to high-performing schools and safe, affordable neighborhoods that make working, living and raising a family special. There are many opportunities for educational advancement including the University of Pittsburgh at Johnstown, Saint Francis University, and Mount Aloysius College.

Why Choose Us:

·         Health (Medical, Dental, Vision) and 401K Benefits for full-time employees

·         Competitive Paid Time Off / Extended Illness Bank package for full-time employees

·         Employee Assistance Program – mental, physical, and financial wellness assistance

·         Tuition Reimbursement/Assistance for qualified applicants

·         Professional Development and Growth Opportunities

·         And much more…

Position Summary:

Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.

Reports to: Director Health Information Management

EEOC Statement:

Conemaugh Health System is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.


Minimum Qualifications:  High School Diploma or equivalent.  Bachelor's Degree required. 

Work Experience:

1. Prior experience in clinical documentation improvement and care management.

2. Minimum of 3 years’ experience in an acute care facility for RNs with demonstrated critical thinking skills.

3. Process improvement in an acute care facility preferred or equivalent experience.

4. Coding skills with knowledge of CMS Inpatient Prospective Payment System and working knowledge of AHA Coding Clinic.

Skills:

1. Strong computer skills, prefer experience with Microsoft Office products including Excel.

2. Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement (CDIP) credentials preferred

3. Excellent demonstrated oral, written and communication skills.

4. Must be initiative-taking.

Licensed Registered Nurse (RN), RHIA, RHIT, Licensed Practical Nurse (LPN), or combination thereof Preferred.


Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran
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