Clinical Documentation Specialist - Behavioral Health Nursing

Job Requisition #: JR59991

End Date: 12/10/2021

Location: Wilmington, Delaware

Position Type: Nursing

Shift: Day Shift, No Rotation

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Are you interested in driving healthcare forward? Some of the best hospital care available in the United States is right here in Delaware! 

ChristianaCare, a healthcare organization with 1100 beds between two Magnet® recognized hospitals (Christiana and Wilmington) and the only Level 1 Trauma service on the East Coast corridor between Philadelphia and Baltimore. Honored repeatedly as "One of America's Best Hospitals" by U.S. News & World Report!

Christiana Care is currently seeking a Clinical Documentation Specialist - Behavioral Health Nursing

We offer robust healthcare benefits, tuition reimbursement, competitive pay and a 403b plan.

Make a difference in the lives of our patients.

Forbes Magazine named us as a Top Best Employer.

Responsible to ensure that health care services are administered with quality, cost efficiency, and within compliance, along with improving and ensuring the overall quality, cost efficiency and completeness of documentation within the inpatient medical record. Continuously reviewing and auditing patient medical records (Psych Crisis and inpatients), screening for unnecessary procedures, ineffective treatments, and unnecessarily extensive hospital stays. Educates members of the patient care team on documentation guidelines on an ongoing basis. Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, coding staff and other members of the healthcare team to support the appropriate reimbursement and clinical severity are captured compliantly for the level of service rendered to all patients. 

-  Concurrent review of inpatient medical records (Psych Crisis and inpatient) throughout the patient's hospitalization.

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

-  Obtains continued insurance authorization for continued stay of patients

-  Obtain initial insurance authorization for direct admissions and admissions from medical units as needed

-  Obtains Electro Convulsive Therapy (ECT) insurance pre-auth as needed for inpatient

-  Communicates with physicians or other providers to validate admission status and appropriately prompts for documentation if necessary, either verbally or written.

-  Educates physicians and other key healthcare providers regarding clinical documentation improvement 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.

-  Maintains confidentiality of patients/members and staff information.

-  Attends coding/financial/utilization management educational programs and regulatory educational programs and updates as necessary to maintain proficient knowledge base.

-  Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.

-  Performs other related duties as required.

-  Bachelor's Degree in Nursing

-  Registered RN licensed to practice in the State of DE required

-  Minimum of 3 years recent experience as a Registered Nurse. Acute care psych preferred.

-  Clinical Documentation, Performance Improvement, Case Management or Utilization Management experience desirable.

-  Clinical Documentation Certification (CCDS) required within 1 year of eligibility.

Hours: The hours for this position are typically Monday - Friday 8 a.m. - 4:30 p.m. No weekends or holidays.

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.

Why do WE offer careers full of possibilities?

For the Love of Health.

Inclusion & Diversity

At ChristianaCare, we’re committed to treating everyone with dignity and respect. We believe in a safe, inclusive work environment that fosters collaboration between caregivers from all walks of life. We know that each unique viewpoint is vital in delivering high-quality, safe patient care to everyone who walks through our doors. Our policies, benefits, hiring practices, employee resource groups, and corporate citizenship demonstrate our commitment to inclusion and diversity throughout our system.

Why do we embrace inclusion and diversity? For the Love of Health.

Our Values

We serve together in Love and Excellence. Our unique values, Love and Excellence are bold and powerful, and they are the reason why working for ChristianaCare is special. The behaviors associated with our values guide how caregivers interact with everyone they work with and make for an exceptional work experience. We believe that when you lead with Love, Excellence is inevitable.


ChristianaCare’s comprehensive total rewards package is one of the most competitive in the region. We are proud to offer excellent benefits that reflect the organization’s commitment to being exceptional today and even better tomorrow.

At ChristianaCare, we provide access to high-quality and affordable benefits designed to meet our caregivers where they are. You can tailor your benefits to meet your needs now and adjust them as your priorities change.

Take advantage of ChristianaCare’s wide-ranging benefit offerings from supporting optimal health through medical, prescription, dental and vision coverage to valuable wellness and work/life programs, which include paid parental leave, coverage for infertility and assisted reproductive technologies, an employer-funded short-term disability program, and more.

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Our Region

A Great Place To Live

Our region offers a diversity of cultures, lifestyles, sports and entertainment events, housing options and educational opportunities. Located between Philadelphia and Washington, D.C., our locations provide easy access to two international airports, employment opportunities in a tri-state area, and proximity to some of the nation's top universities and colleges, as well as beaches in MD, DE and NJ!

Why Delaware? Why Maryland?

We Serve Together

For the Love of Health

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