Clinical Documentation Spec

Cooper University Hospital • Camden, NJ

4d

About The Position

Responsible for ensuring the overall quality and completeness of medical record documentation. 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. Professional team player, able to communicate well with others on all levels. Regular significant contacts with other personnel throughout and outside the hospital. Contacts may be in person, by telephone or-through correspondence. Flexible with a working knowledge of all areas of adult medicine. Occasional lifting/carrying up to fifteen pounds, as well as reaching, stretching, stooping, bending, kneeling, crouching, standing, walking and pushing/pulling to move and file medical records alone or in carts. Ability to sit for 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

• Knowledge of medical record documentation requirements coding guidelines
• Computer knowledge of Epic a plus
• RN preferred or CCS, CPC or RHIT preferred
• NJ-RN License (Registered Nurse) preferred CCS, CPE or RHIT preferred
• Essential mental abilities: good critical thinking skills, able to assess, evaluate and teach
• Requires excellent observation skills, analytical thinking, problem solving, computer skills, good verbal and written communication

Responsibilities

• ensuring the overall quality and completeness of medical record documentation
• 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

Benefits

• health
• dental
• vision
• life
• disability
• retirement
• opportunities for career growth through professional development

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees