Clin Documentation Spec III, RN & Coding Certification Required

Cooper University Hospital•Camden, NJ

21h•Remote

About The Position

Responsible for ensuring the overall quality and completeness of medical record Documentation for all payor groups, all DRG’s, including MS, AP, and APR. Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis, as needed. Professional team player, able to communicate well with others on all levels. Regular electronic contacts with other personnel throughout and outside the hospital Contacts may be in by telephone or through e-mail correspondence. Flexible with a working knowledge of all areas of adult medicine.

Requirements

EPIC EHR Clintegrity CDE software
5 years minimum experience as Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center.
CDI Subject matter expert for ALL PAYORS, all DRG groups (MS-DRG, APR-DRG, AP-DRG)
PSI/HAC/HCC (Risk adjustment coding) knowledge/experience
Registered Nurse, any state.
CCDS or CDIP
Coding certification: CCS or CRC

Nice To Haves

BSN or higher preferred

Responsibilities

Ensuring the overall quality and completeness of medical record Documentation for all payor groups, all DRG’s, including MS, AP, and APR.
Facilitating modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients.
Supporting timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
Educating all members of the patient care team on an ongoing basis, as needed.