Clin Documentation Spec III - Remote

Cooper Norcross University Hospital • Camden, NJ

3d • $41 - $70 • 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 caregivers, and Health Information coding staff to support appropriate reimbursement and clinical severity capture 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. Acts as a professional team player, able to communicate well with others on all levels. Engages in regular electronic contact with other personnel throughout and outside the hospital via telephone or e-mail correspondence. Flexible with a working knowledge of all areas of adult medicine. Requires the ability to sit for long periods, manual dexterity, and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer, and other office equipment. Must be adequate to perform essential functions of the job with the type of judgments and potential consequences outlined.

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 caregivers, and Health Information coding staff to support appropriate reimbursement and clinical severity capture 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.
• Communicating well with others on all levels.
• Engaging in regular electronic contact with other personnel throughout and outside the hospital via telephone or e-mail correspondence.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior