Clinical Documentation Specialist

Atlantic Health System • Morristown, NJ

391d

About The Position

The Clinical Documentation Specialist at Atlantic Health System plays a crucial role in enhancing the quality of clinical documentation through direct interactions with healthcare providers. This position involves reviewing patient medical records to ensure accurate representation of clinical severity, complications, and co-morbidities, thereby supporting appropriate coding and reimbursement processes. The specialist will also educate clinical staff on documentation practices and identify quality care issues, contributing to overall performance improvement within the healthcare system.

Requirements

• Licensed Registered Nurse credentialed from the NJ Board of Nursing.
• Three years of relevant experience in an acute-care setting, preferably in surgical, intensive care, or emergency medicine.
• Advanced understanding of anatomy, physiology, pathophysiology, and pharmacology.
• Knowledge of CMS regulations and DRG groupings.
• Experience with ICD-10-CM/PCS coding and AHA Coding Clinic guidelines.

Nice To Haves

• Prior experience in Clinical Documentation Improvement (CDI) is preferred.
• Knowledge of word processing, spreadsheet, and reporting software.
• Experience with encoder software and electronic medical records.

Responsibilities

• Facilitate modifications to clinical documentation through interactions with physicians and clinicians.
• Review and evaluate selected patient medical records for quality and completeness.
• Educate physicians and coding professionals on documentation opportunities and coding issues.
• Identify quality of care issues in documentation and seek resolution through appropriate channels.
• Conduct case audits, including initial, concurrent, and final reviews of medical records.
• Collaborate with coding staff to ensure accurate coding and documentation of diagnoses and comorbid conditions.
• Develop and conduct ongoing education for clinical documentation specialists and medical staff.
• Utilize compliant query processes for documentation improvement and follow through to closure.

Benefits

• Competitive salary range of $74.4K - $94.3K per year.
• Opportunities for professional development and education.
• Recognition as one of the best places to work in healthcare.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: No Education Listed
• Number of Employees: 10,001+ employees