Clin Documentation Spec III

Cooper University Hospital • Camden, NJ

2d • 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. Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer and other office equipment. Adequate to perform essential functions of the job with the type of judgments and potential consequences outlined above.

Requirements

• EPIC EHR
• Clintegrity CDE software
• 5 years minimum experience as a Clinical Documentation Specialist in an acute setting, preferably a 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
• BSN or higher preferred

Responsibilities

• Ensuring the overall quality and completeness of medical record documentation for all payor groups and DRG’s (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 capture clinical severity 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.

What This Job Offers

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