Clinical Documentation Specialist

Atlantic Health System • Pequannock Township, NJ

1d • $48 - $85 • Onsite

About The Position

Responsible for reviewing patient medical records throughout hospitalization to capture accurate representation of the severity of illness and facilitate proper coding. Validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.

Requirements

• Reviewing patient medical records throughout hospitalization
• Capturing accurate representation of the severity of illness
• Facilitating proper coding
• Validating that coding reflects medical necessity of services
• Ensuring appropriate coding for accurate reflection and reporting of severity of illness, expected risk of mortality, and complexity of care

Responsibilities

• Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
• Creates job aids and queries in support of training initiatives
• Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart
• Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding
• Discusses cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings
• Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured
• Serves as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement efforts
• Performs other relevant duties as assigned

Benefits

• Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
• Life & AD&D Insurance.
• Short-Term and Long-Term Disability (with options to supplement)
• 403(b) Retirement Plan: Employer match, additional non-elective contribution
• PTO & Paid Sick Leave
• Tuition Assistance, Advancement & Academic Advising
• Parental, Adoption, Surrogacy Leave
• Backup and On-Site Childcare
• Well-Being Rewards
• Employee Assistance Program (EAP)
• Fertility Benefits, Healthy Pregnancy Program
• Flexible Spending & Commuter Accounts
• Pet, Home & Auto, Identity Theft and Legal Insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Principal
• Education Level: No Education Listed