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Poa Surgery Center information

What is the difference between Poa Surgery Center vs Anesthesiologist?

AspectPoa Surgery CenterAnesthesiologist
CredentialsMedical license, specialized surgical trainingMedical license, anesthesia certification (CA-1, CA-2, CA-3)
Work EnvironmentOutpatient surgical facilities, clinicsHospitals, surgical centers, clinics
Industry UsageProvides surgical procedures, patient careAdministers anesthesia, manages pain control

While Poa Surgery Center focuses on providing outpatient surgical services, Anesthesiologists specialize in administering anesthesia and managing patient pain during surgeries. Both roles require medical licenses, but their responsibilities and work environments differ significantly.

What cities are hiring for Poa Surgery Center jobs? Cities with the most Poa Surgery Center job openings:

Clinical Documentation Integrity Registered Nurse - Full Time

Indiana Regional Medical Center

Indiana, PA • On-site

$31.75 - $42.75/hr

Full-time

Posted 2 days ago

Indiana Regional Medical Center rating

5.8

Company rating: 5.8 out of 10

Based on 22 frontline employees who took The Breakroom Quiz

856th of 999 rated hospitals

Job description

In this role you will:
  • Conduct concurrent and retrospective reviews of inpatient and observation medical records to ensure documentation accurately reflects the patient's clinical condition, acuity, and medical necessity.
  • Identify documentation improvement opportunities related to:

    • Principal and secondary diagnoses
    • Present on Admission (POA) indicators
    • Severity of Illness (SOI) and Risk of Mortality (ROM)
    • Clinical validity and CMS/payer expectations

  • Initiate compliant, well-supported physician queries following AHIMA and ACDIS guidelines.
  • Collaborate with Coding, HIM, Case Management, Revenue Cycle, and medical staff to ensure complete, accurate, and consistent documentation throughout the record.
  • Provide targeted provider education on documentation requirements, clinical indicators, and specialty-specific opportunities for improvement.
  • Assist with denial prevention and payer audit response by clarifying documentation and supporting clinical validation reviews.
  • Monitor CDI program performance metrics (e.g., query rate, agreement rate, impact on SOI/ROM, query response rate) and contribute to reporting and analysis.
  • Participate in CDI and documentation-related committees, workgroups, and performance improvement initiatives.
  • Support accurate quality measure abstraction through improved documentation consistency (PSIs, mortality metrics, core measures, risk adjustment elements, etc.).

Quality, Regulatory, and Performance Improvement
  • Ensure adherence to all CMS Conditions of Participation (CoPs), CMS documentation requirements, and applicable state and regulatory guidelines.
  • Partner with Quality to provide input for dashboards, metric reporting, and committee presentations as assigned.
  • Support organizational goals related to:

    • Mortality reduction
    • Patient safety
    • Documentation accuracy
    • Denial mitigation and audit readiness

  • Participate in regulatory surveys, mock audits, and internal readiness assessments related to documentation integrity.
  • Promote HRO principles and proactive identification of documentation risks or patterns impacting quality reporting or compliance.

OTHER DUTIES
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
QUALIFICATIONS
Required:
  • EDUCATION:
    • Graduate of an accredited School of Nursing (ADN or BSN).
    • Current Registered Nurse (RN) license in good standing.
    • Completion of hospital-required clinical competencies and continuing education.
    • Bachelor of Science in Nursing (BSN) strongly
    • Master's degree in Nursing, Healthcare Administration, Quality, or related field (preferred but not required).
    • Formal training or coursework in: Clinical Documentation Integrity; Quality improvement / performance improvement; High Reliability Organization (HRO) principles desirable

  • EXPERIENCE:
    • Minimum 3 years of acute care clinical experience (ICU, ED, or medical-surgical strongly preferred).
    • Strong understanding of clinical documentation standards, coding principles, and evidence-based sepsis care.
    • Prior CDI experience preferred
    • Experience in clinical validation or working with Coding/HIM
    • Experience with payer audits, utilization review, quality improvement, or risk adjustment concepts preferred
  • LICENSURE/CERTIFICATION:
    • Current Registered Nurse (RN) license in good standing
    • Highly desirable:
      • CCDS - Certified Clinical Documentation Specialist (ACDIS)
      • CDIP - Clinical Documentation Improvement Practitioner (AHIMA)
      • CPHQ - Certified Professional in Healthcare Quality
      • Lean Six Sigma Yellow or Green Belt

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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