Clinical Documentation Specialist
Primary location: Morristown,NJ
Schedule: Full-time
Type: Finance/Accounting/Billing/PFS
Shift: M to F 8am to 4pm
Job ID: 4562
The Clinical Documentation Specialist will facilitate modifications to clinical documentation, through concurrent interactions with physicians and other clinicians to reflect appropriate clinical severity, complications and co-morbidity.
The specialist shall concurrently review and evaluate selected patient’s medical records for overall quality and completeness. Will educate physicians, non-physician clinicians, coding professionals on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities.
Will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels.
90%- Case Audits Initial. Concurrent and Final
10%- Participate in Subcommittees for various Disciplines
Reviews medical records of hospitalized patients to identify the most appropriate principle diagnosis and to assign a working DRG. Performs initial reviews, concurrent reviews and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study.
Completes the initial review within 24-48 hours of admission.
Completes concurrent reviews to ensure working DRG, SOI and ROM and all comorbid conditions are documented by the providers to the greatest specificity
Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
Educates internal staff on clinical documentation and coding guidelines. Develops and conducts ongoing education for new clinical documentation specialists, coders, physicians, residents.
Develops and supports strong professional relationships with CDS, Coding staff, Physician advisors and medical providers across the system.
Utilizes a compliant query process per guidelines and policy when conducting all queries.
Follows each query through to closure including complete documentation of ongoing follow up activities and communication.
Provides ongoing CDS team learning opportunities through sharing of professional knowledge.
Maintains integrity and compliance in all chart reviews and CDI documentation and queries.
Supports and implements quality measures as identified by AHS system
Education:
Licensed Registered Nurse credentialed from the NJ Board of Nursing
Licenses:
NJ RN License required
Required Experience:
Required and minimum of three years of experience in the acute-care setting in: surgical, intensive care, emergency medicine preferred. An advanced understanding of anatomy, physiology, pathophysiology and pharmacology is required.
Preferred prior CDI experience required.
Certifications:
On of the following preferred: CCDS, CDIP, CCS
Other:
Knowledge of word processing software, spreadsheet software and reporting software. Also, experience working with encoder software, clinical documentation improvement software and the electronic medical record is preferred 3M EPIC Iodine
Demonstrates excellent interpersonal relationship skills
Capable of acting independently
Knowledge of CMS regulations along with DRG groupings
Coding skills with experience in ICD-10-CM/PCS and working knowledge of the AHA Coding Clinic (some training provided)
Requires ability to work with and maintain confidential information.
Communicate with and educate members of the patient care team (physicians and advanced practice providers) and others on the clinical documentation concepts.
About US
ABOUT US
At Atlantic Health System, our promise to our communities is; Anyone who enters one of our facilities, will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 20,000 team members. Headquartered in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:
- Morristown Medical Center, Morristown, NJ
- Overlook Medical Center, Summit, NJ
- Newton Medical Center, Newton, NJ
- Chilton Medical Center, Pompton Plains, NJ
- Hackettstown Medical Center, Hackettstown, NJ
- Goryeb Children’s Hospital, Morristown, NJ
- CentraState Healthcare System, Freehold, NJ
- Atlantic Home Care and Hospice
- Atlantic Mobile Health
- Atlantic Rehabilitation
We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.
We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:
- 100 Best Companies to Work For ® and FORTUNE® magazine for 15 years
- Best Places to Work in Healthcare – Modern Healthcare
- 150 Top Places to work in Healthcare – Becker’s Healthcare
- 100 Accountable Care Organizations to Know – Becker’s Hospital Review
- Best Employers for Workers over 50 – AARP
- Gold-Level “Well Workplace”: Wellness Council of America (WELCOA)
- One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine
- One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine
- Official Health Care Partner of the New York Jets
- NJ Sustainable Business
EEO STATEMENT
Atlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.
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