Clinical Documentation Specialist- Per Diem

Thomas Jefferson University • Philadelphia, PA

4d • Remote

About The Position

Under the direction of the CDI Manager, the Clinical Documentation Specialist reviews medical records to facilitate accurate and complete medical record documentation. This role ensures that documentation reflects clinical treatment, decisions, and diagnoses used for measuring and reporting hospital and physician outcomes. The specialist identifies opportunities for additional documentation, places appropriate queries, and communicates with physicians, coders, and other health team members to improve documentation. This position works independently and primarily in an approved remote home work environment.

Requirements

• Bachelor of Science in Nursing, Bachelor of Science in Health Information Management or related field. Certification, Associate or Bachelor in other healthcare related field with experience noted below.
• Expert working knowledge of HIPPA PHI and all laws relative to access PHI (protected Health Information).
• Demonstrates working effectively and independently in a remote home work environment, and effectively troubleshoots systems issues in accordance with department policy and procedures.
• Familiarity with computers and Microsoft Office applications required.
• Ability to work independently with minimal supervision.
• Motivated, organized with excellent interpersonal skills, analytical skills.
• Ability to read and communicate in the English Language.

Nice To Haves

• CCDS, CDIP certification preferred.
• RN/BSN preferred.
• RHIA, or RHIT with CCS, MD or DO will be considered.
• CCDS within 6 months of hire for eligible candidates.
• Working knowledge of Medicare reimbursement system and coding structures preferred.
• 5 years of Critical Care/Emergency medicine or 5 years of Medical Surgical Experience preferred.
• 2-3 years Clinical Documentation Improvement experience or 5 years of Coding experience preferred.
• MD/DO with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered.
• Strong facilitation and presentation skills preferred.

Responsibilities

• Accurately reviews medical records concurrently for completeness in documentation of diagnostic and procedural information for compliance to CMS, DOH regulatory, and financial requirements.
• Assures documentation of diagnoses, procedures, co-morbid, and complication conditions are reflected on the medical record to support proper severity of illness, intensity of service, and risk of mortality classifications and designated quality reviews.
• Prepares well-written and compliant queries to communicate with physicians and other providers regarding missing, incomplete, or clarifying information needed in the medical record.
• Works closely with coding staff to assure that documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
• Interacts and continuously educates physicians (attending’s, residents and interns), nurse practitioners and physician assistants.
• Provides real-time intervention/education when needed to promote correct coding, regulatory compliance, and correction of documentation deficiencies.
• Maintains productivity expectations.
• Accurately records activity in CDI software tracking tool.
• Reviews medical record for other identified regulatory requirements as applicable.
• Tracks and trends issues identified during concurrent reviews.
• Actively contributes to the continued improvement and success of the department and the hospital.
• Attends continuing education meetings, in-services, and training sessions and audioconferences related to coding and CDI to maintain skills and stay abreast of coding guideline changes and best practice CDI processes.
• Demonstrates initiative, judgment, and creative ability in performance of job duties.
• Identifies problems with process and suggests possible solutions.
• Functions in a professional, efficient, and positive manner.
• Performs other duties and assignments as necessary.

Benefits

• medical (including prescription)
• supplemental insurance
• dental
• vision
• life and AD&D insurance
• short- and long-term disability
• flexible spending accounts
• retirement plans
• tuition assistance
• voluntary benefits
• tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level