Atlantic Health System
Location
Morristown, NJ | United States
Job description
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
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
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