Clinical Documentation Specialist - Health Information Management

Job ID #: 24154

Employment Type: Full - Time

Location: Einstein Medical Center Philadelphia

Weekends Required? No

Rotation Required? No

On-Call Required? No

Entity: Tabor Acute Care

Department: Health Information Mgt - TB

Shift: day

Biweekly Hours: 75

Experience Required: 5 - 7 Years

City: Philadelphia

State: PA

Zip Code: 19141-3018

Position Description

Einstein Healthcare Network is a private, not for profit organization with several major facilities and many outpatient centers. Our primary mission is to provide compassionate, high quality healthcare to the greater Philadelphia region. Einstein Healthcare Network promotes wellness.  Research has shown that smoking is dangerous to the health of smokers and to others.  Einstein campuses are Tobacco and Smoke Free.


In this role you will be responsible for:

• Through extensive interaction with Physicians and multidisciplinary team members the CDS will be responsible for facilitating modifications to the overall quality and completeness of medical record documentation.
• This will support the appropriate clinical picture / level of severity of the patient while providing accurate and complete information that is utilized in the medical record abstraction and coding process.

• Extensive clinical knowledge and understanding of pathophysiology demonstrated by experience working in an acute care hospital setting.
• Excellent written and verbal communication skills with the ability to write and speak concisely and professionally when communicating with providers
• Self-motivated with strong critical thinking and problem solving skills.
• Must possess the ability to create and deliver clinical education programs on CDI for the medical and hospital staff.
• Working knowledge of PC applications required, including Microsoft Windows Application (Word, Excel, and Powerpoint).
• Knowledge of ICD 10 CM/PCS coding classification system and MS/APR DRG is preferred.
• RN with acute care experience in Critical Care or Emergency Department within the last 5 years required or Care Management experience in the last 5 years with prior RN experience in Critical Care or Emergency Department OR minimum of 1 year previous CDI experience.

• Physical Requirements: Sitting, Standing, Lifting, and Walking, Agility, Dexterity
• Visual Requirements: Near Vision, Depth Perception, Color Vision, Extensive exposure to VDT�s (Video Display Terminal)
• Hearing Requirements: Ability to hear normal conversation, telephone communication, hear low voice volumes, whispers
• Working Conditions: Office Setting in Health Information Management Department

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.