CentraState Healthcare System
Location
Freehold, NJ | United States
Job description
The Clinical Documentation Improvement Specialist (CDIS) will perform concurrent analytical review of clinical and coding data with a goal of improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, severity of illness & risk of mortality profiling, and reimbursement. The CDIS will facilitate the resolution of queries as well as educate members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians, allied health practitioners, nursing, and case management. Finally, the CDIS will collaborate with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
Education:
Bachelor's Nursing Preferred
Additional Educational Requirements
Graduate of an accredited school of Registered Nursing
Work Experience:
1 Year Coding Experience Preferred
2 Years Clerical Experience In A Healthcare Environment Required
Licenses and Certifications:
Current NJ RN License Required
Additional Certification/Licensure Requirements
CCDS must be obtained within two years of hire. Certified Coding Specialist designation (CCS, CSS, CCS-P from AHIMA) preferred.
Required Knowledge and Skills:
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Excellent written and verbal communication skills, excellent critical thinking skills. Excellent interpersonal skills to build effective partnering relationships with physicians, nurses, and hospital staff. Ability to work independently in a time oriented environment. Working knowledge of inpatient admission criteria. Working knowledge of Medicare reimbursement system and coding structures desired. An understanding of coding classifications systems such as, but not limited to, ICD-9/10CM, APR-DRG preferred. Knowledge of care delivery documentation systems and related medical record documentation. Prior documentation specialist experience preferred.
CentraState Healthcare System, a partner of Atlantic Health System, is a fully accredited, not-for-profit, community-based health system that provides comprehensive health services in the central New Jersey region. In addition to offering a full range of leading-edge diagnostic and treatment options, CentraState serves as a valuable health partner focused on the latest ways to prevent disease, promote healthy behaviors, and help people of all ages live life well. Based in Freehold, CentraState is comprised of a 284-bed acute-care hospital, a vibrant health and wellness campus, three award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions offering primary care and specialty physician practices, along with access to outpatient services, such as lab and physical therapy. The system also offers a family medicine residency and geriatric fellowship training program in affiliation with Rutgers Robert Wood Johnson Medical School. Among its many honors and accreditations, CentraState is one of less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence four times and was designated a Great Place to Work-Certified™ Company by Great Place to Work® for the second consecutive year.
When you bring your talent to CentraState, you are joining a trailblazing healthcare facility, committed to providing high-quality, patient-focused care. Join us in making incredible strides in health care, and making a difference in our community. We believe in enriching the lives of our employees through work/life balance initiatives, tuition assistance, career advancement opportunities and much more.
Find out why our employees love their jobs and being part of the CentraState family!
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