**Description** Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? Entity: Corporate Services Department: Corp HIM CDI Location: 1500 Market Street Hours: M-F 8a-4:30p, Remote The Health Information Management (HIM) Clinical Documentation Specialist will oversee organization-wide system for improving clinical documentation in the medical record. Plan, organize, design, implement and monitor coding initiatives to improve coding quality and reimbursement. Provide individual and group education to Coding staff, Clinical Documentation Improvement (CDI) Specialists, Providers and others throughout the organization that requires coding and documentation knowledge. Assist Coding Management staff in performing quality audits on coding staff and assist with management of the provider query process. Provide back up as necessary for reviews related to departmental and health system quality initiatives. Process clinical validation denials by disputing payer payment reductions when appropriate through identification of supportive documentation, clinical indicators, and treatment noted in the patient's encounter with a strong foundation in payer criteria and established clinical definitions. Develop and maintain data, quality metrics and dashboards for Leadership. Accountabilities 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 Minimum Requirements Required Education and Experience Bachelor's Degree in Nursing, Health Information Management or related field is required. (Master’s preferred) 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 Licenses, Registrations, and Certifications Current PA licensed RN, RHIA, RHIT or CCS Required Skills and Abilities 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. We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law. REQNUMBER: 269937