Penn Medicine, University of Pennsylvania Health System · 3 hours ago
HIM Retrospective Clinical Documentation Specialist
Philadelphia, PA
Full-time
Hybrid
Senior Level
5+ years expPenn Medicine is dedicated to providing high-quality patient care, conducting innovative research, and educating future leaders in medicine. The HIM Clinical Documentation Specialist will oversee the system for improving clinical documentation, plan and implement coding initiatives, and provide education to staff on documentation knowledge.
BiotechnologyEducationHealth CareMedicalTraining
Responsibilities
Ensure that inpatient clinical documentation accurately reflects severity of illness and intensity of service
Ensure that present on admission (POA) clinical conditions are charted appropriately within defined regulatory timeframes
Communicate with Physician or designee requesting appropriate recommendations for documentation improvement
Perform targeted chart reviews using various of risk adjustment methodologies to facilitate accurate reporting of mortality statistics
Perform chart reviews to reflect accurate safety rating scores and quality of care statistics
Assist HIM Coding Quality team with clinical validation audits and provide support for coding quality initiatives
Active participation in team meetings and educational presentations to CDI Specialists, Coders, various Physician groups and others on specific documentation improvement topics
Process clinical validation payer denials utilizing payer-specific criteria, established definitions, and assessment of chart documentation
Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
Other duties as assigned to support the unit, department, entity, and health system organization
Qualification
Required
Bachelor's Degree in Nursing, Health Information Management or related field is required
5+ years of Clinical experience in Nursing and/or HIM or related field
1+ years of Clinical Documentation Improvement (CDI) Specialist and/or coding quality experience
1+ years of CCU/ICU acute care clinical experience
Current PA licensed RN, RHIA, RHIT or CCS
Strong knowledge of MS-DRG's and medical record documentation requirements are essential
Ability to analyze complex clinical scenarios and apply critical thinking
Possess basic computer skills in word processing and spreadsheet utilization
Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary
Ability to interpret, adapt, and apply guidelines and procedures
Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding
High level of creativity, judgment, and initiative, tempered with flexibility to deal with a rapidly changing healthcare environment and expanding technology
Self-motivated, well-organized, and possess excellent communication and analytical skills, as well as, strong facilitation and presentation/education skills required
Ability to maintain concentration with attention to detail
Preferred
Master's preferred
Benefits
Prepaid tuition assistance programs
Company
Penn Medicine, University of Pennsylvania Health System
Penn Medicine is a world leader in academic medicine, setting the standard for cutting-edge research, compassionate patient care, and the education of future health care professionals.
10001+ employees
Funding
Current Stage
Late StageTotal Funding
$70.9MKey Investors
BIRD FoundationWarren Alpert FoundationNational Cancer Institute
2025-01-22Grant
2023-01-03Grant· $9.7M
2022-08-18Grant· $5.7M
Leadership Team
Kevin Mahoney
Chief Executive Officer of University of Pennsylvania Health System
John Donohue
Vice President, Enterprise Services
Recent News
The Philadelphia Inquirer
2026-01-03
Company data provided by crunchbase