Clinical Documentation Specialist RN

Jersey Shore University Medical Center • Wall Township, NJ

69d

About The Position

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. The Clinical Documentation Specialist RN facilitates improvement in the overall quality, completeness and accuracy of medical record documentation for assigned hospital/s of Hackensack Meridian Health (HMH). Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department (ETD), to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of the patient care team on documentation guidelines, on an on-going basis. Reviews and screens ED inpatient admissions and observations as specified by the facility's Utilization Management/Review Committee for documentation completeness and compliance with patient status. Facilitates accurate documentation for severity of illness and medical necessity. Interacts with physicians, case managers, and nursing staff and provides guidance and recommendations for admission or observation disposition. Assesses patients for present-on-admission (POA) conditions to ensure accurate documentation, regarding hospital acquired conditions (HAC). Communicates the transfer of appropriate concurrent information to the inpatient Case Managers and the Clinical Documentation Specialists (CDS), assigned to the unit.

Requirements

• Graduation from a bachelor's level program of Nursing.
• Minimum of 5 or more years of recent clinical experience, preferably in Medical/Surgical Critical Care, Intensive Care or Emergency Room Care.
• Ability to interact well with physicians and other members of allied health care team.
• Must be computer literate with knowledge of Microsoft Word and Excel.
• Excellent communication, organizational, analytical, writing and interpersonal skills.
• Dependable, self-directed and pleasant.
• Critical thinking, problem solving and deductive reasoning skills.
• Recent hospital experience.
• Knowledge of Pathophysiology and Disease Process.
• Knowledge of Medicare Part A and B.
• Knowledge of regulatory environment.
• Understanding of CDMP® documentation strategies.
• Knowledge of POA/HAC and core measures.
• Knowledge of Observation and Inpatient medical necessity.
• Knowledge of regulatory requirements for appropriateness of admissions.

Nice To Haves

• Advanced Practice Degree.
• ICU, CCU and/or strong Medical/Surgical experience.

Responsibilities

• Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation.
• Obtains and promotes appropriate clinical documentation through interaction with healthcare staff.
• Educates patient care team members on documentation guidelines.
• Reviews and screens ED inpatient admissions and observations for documentation completeness.
• Facilitates accurate documentation for severity of illness and medical necessity.
• Interacts with physicians, case managers, and nursing staff for guidance on admission or observation disposition.
• Assesses patients for present-on-admission (POA) conditions.
• Communicates concurrent information to inpatient Case Managers and Clinical Documentation Specialists.

Benefits

• Competitive benefits package.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: Bachelor's degree