Clinical Documentation Specialist
Atlantic Health System•Summit, NJ
•$48 - $85•Onsite
About The Position
The Clinical Documentation Specialist facilitates updates to clinical documentation by collaborating with physicians and clinicians to accurately reflect severity, complications, and co-morbidities. Reviews and evaluates patient records for quality and completeness. Educates physicians, nonphysician clinicians, and coding staff on documentation, coding, reimbursement, and quality improvement opportunities. Identifies documentation-related quality of care issues and resolves them appropriately.
Requirements
- Facilitates updates to clinical documentation by collaborating with physicians and clinicians to accurately reflect severity, complications, and co-morbidities.
- Reviews and evaluates patient records for quality and completeness.
- Educates physicians, nonphysician clinicians, and coding staff on documentation, coding, reimbursement, and quality improvement opportunities.
- Identifies documentation-related quality of care issues and resolves them appropriately.
Responsibilities
- Review medical records to assign accurate DRG
- Perform initial, concurrent, and retrospective reviews
- Complete initial review within 24–48 hours of admission
- Ensure SOI, ROM, and comorbidities are documented
- Collaborate with coding staff for accurate documentation
- Educate staff on documentation and coding guidelines
- Train new CDS specialists, coders, physicians, residents
- Share knowledge for ongoing team learning
- Maintain compliance in chart reviews and queries
- Support quality measures and system initiatives
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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
