Clinical Documentation Specialist (RN)

Clinical Documentation Integrity Specialist (RN)

FT M-F (Hours: Day Shift - Remote Work with onsite presence when needed.

Newark, DE

ChristianaCare Hospital in Newark, DE, is seeking a Registered Nurse (RN) with experience as a Clinical Documentation Specialist to join our Clinical Documentation Improvement Team. In this role, the Clinical Documentation Specialist will ensure that healthcare services are provided with quality, cost efficiency, and compliance.

The position involves enhancing and maintaining the overall quality, cost efficiency, and completeness of documentation within inpatient medical records. Responsibilities include ensuring the accuracy of documented diagnoses and supporting clinical indicators.

The specialist will facilitate modifications to clinical documentation through ongoing collaboration with the Physician Advisor, physicians, coding staff, and other members of the healthcare team. This teamwork is essential for capturing appropriate reimbursement and accurately reflecting the clinical severity of the services provided to all patients in a compliant manner.

ChristianaCare Offers:

• Full Medical, Dental, Vision, Life Insurance, etc.
• Two retirement planning offerings, including 403(b) with company contributions.
• Generous paid time off with annual rollover and opportunities to cash out.
• 12-week paid parental leave.
• Tuition assistance
• Incredible Work/Life benefits including annual membership to care.com, access to backup care services for dependents through Care@Work, retirement planning services, financial mentor, fitness and wellness reimbursement, and great discounts through several vendors for hotels, rental cars, theme parks, shows, sporting events, movie tickets, and much more!

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Delaware RN License or Compact Nursing License required.
• Bachelor's Degree in Nursing
• Strong medical terminology & clinical awareness
• Effective communication and clinical skills
• Clinical Documentation Certification (CCDS) required within 1 year of eligibility.
• Required: 3 years of experience as a Registered Nurse in an acute care hospital setting.
• Preferred: 2-3 years of experience in Clinical Documentation Improvement (CDI).
• Completes a minimum of 8 continuing education credits (CEUs) per year in Clinical Documentation Improvement.

KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:

• 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
• Accountability Act of 1996 (HIPAA)
• Knowledge of Performance Improvement Principles.
• Ability to work efficiently and independently.
• Ability to collaborate with clinicians and administrative staff.
• Ability to utilize computer applications on various platforms.
• Ability to manage multiple projects with constant shifts in priority.

Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.

Post End Date

EEO Posting Statement

ChristianaCare offers a competitive suite of employee benefits to maximize the wellness of you and your family, including health insurance, paid time off, retirement, an employee assistance program. To learn more about our benefits for eligible positions visit https://careers.christianacare.org/benefits-compensation/