Headquartered in Wilmington, Delaware, ChristianaCare is one of the country's most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible and lowering health care costs. ChristianaCare includes an extensive network of outpatient services, home health care, urgent care centers, three hospitals (1,299 beds), a free-standing emergency department, a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women's health.

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 roll-over 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 coaching, fitness and wellness reimbursement, and great discounts through several vendors for hotels, rental cars, theme parks, shows, sporting events, movie tickets and much more!

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Concurrent review of inpatient medical records throughout the patient's hospitalization.

o Analyzes clinical status of patient, current treatment, past medical history and identifies potential gaps in physician documentation.

• Communicates with physicians or other providers to validate diagnoses, clinical indicators and appropriately prompts for documentation, if necessary, either verbally or written.
• Demonstrates proficient knowledge of HIMS standards of coding and applies to ongoing evaluation of the medical record documentation.
• Educates physicians and other key healthcare providers regarding best practice clinical documentation and the need for accurate and complete documentation in the health record.
• Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
• Monitors patients progress: consults with primary physician or designee and other members of the care delivery team at agreed-upon intervals, or more frequently, as needed.
• Participates in performance improvement activities regarding documentation improvement
• Maintains confidentiality of patients/members and staff information.
• Attends coding/financial/CDI educational programs and regulatory educational programs and updates as necessary to maintain a proficient knowledge base.
• Performs assigned work safely, adhering to established departmental safety rules and practices; reports to manager, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
• Reviews all PSI encounters for completeness and accuracy. Review outcome with Physician Advisors, and Medical Directors, as needed.
• Attends daily huddles with HIMS to address any clinical concerns
• Computes a working DRG to identify the anticipated length of stay. Shared with the care team for LOS goals.
• Uses Vizient data to identify documentation opportunities and targeted physician education.
• Performs other related duties as required

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Bachelor's Degree in Nursing
• Registered RN licensed to practice in the State of DE required (Or compact state)
• Strong medical terminology & clinical awareness
• Effective communication and clinical skills
• Clinical Documentation Certification (CCDS) required within 1 year of eligibility.
• Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred
• Completes a minimum of 8 continuing education credits (CEU'S) per year in Clinical Documentation Improvement
• Remote CDI experience preferred

EEO Statement: 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.

UPDATE: ChristianaCare is committed to prioritizing the health and safety of our patients and caregivers. As we continue to meet the needs of our caregivers and our community through the COVID-19 pandemic, our commitment to health and safety requires that we take new steps to ensure a safe environment for medical care for our patients and a workplace that avoids preventable harm for our caregivers. For this reason, vaccination for COVID-19 is required for all caregivers at ChristianaCare and is considered a safety standard that is job-related and consistent with business necessity for all caregivers.