Clinical Document Improvement Specialist - FT - Day - Clinical Documentation Improvement Trenton NJ

Capital Health (US)

11d • $39 - $51 • Onsite

About The Position

Facilitates improvement of overall quality and completeness of clinical documentation in patient record through extensive interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff. Ensures that medical record documentation provides an accurate representation of the patient's clinical complexity, diagnoses, severity, and expected risk of mortality to support accurate DRG assignment and quality measure reporting. Maintains up-to-date knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Educates members of patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.

Requirements

• Graduate of an accredited school of nursing program. RN, required.
• Two years’ recent clinical experience in an acute care setting, preferable ICU or Medical/Surgical, or three years related coding experience or clinical documentation improvement specialist experience in a hospital setting.
• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
• Excellent verbal and written communication skills.
• Working knowledge of all areas of adult medicine.
• Knowledge of pathophysiology and disease process.
• Intermediate computer skills.
• Familiarity with windows-based software programs and encoding software.
• Ability to work in environment using multiple EMR systems.
• Excellent observation, analytical thinking, and problem-solving skills.
• Ability to learn/develop skills necessary to perform CDI.
• Flexible, dependable and self-directed.
• Ability to work independently.
• Demonstrates ethical conduct.

Nice To Haves

• BSN preferred.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) credential preferred.
• Certification as CCDS or CDIP preferred.

Responsibilities

• Completes initial reviews of patient records within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness
• Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Proactively identifies issues with reporting of diagnostic testing.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Fosters teamwork and collaboration. Meets or exceeds departmental accuracy and productivity standards.
• Attends hospital or Medical Staff meetings to review or respond to documentation related issues.
• Provides technical assistance to the Medical Staff and patient care providers to efficiently navigate the electronic medical which could reside in multiple systems
• Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality
• Reviews and clarifies clinical issues in health record with coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
• Facilitates change processes required to capture needed documentations, such as EMR template redesign
• Support pre-bill or post-bill reviews to address documentation gaps impacting reimbursement or quality measures.
• Maintains a level of expertise by attending continuing education programs.

Benefits

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA)
• Healthcare FSA
• Dependent Care FSA
• Retirement Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits – Long Term Disability (LTD)
• Disability Benefits – Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance
• Voluntary Life Spouse
• Voluntary Life Employee
• Voluntary Life Child
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree