Clinical Documentation Spec

Overview

Job Description
:
Responsible for reviewing patient medical records throughout hospitalization to capture accurate representation of the severity of illness and facilitate proper coding. Validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.

• Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
• Creates job aids and queries in support of training initiatives
• Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient s chart
• Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding
• Discusses cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings
• Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured
• Serves as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement efforts
• Performs other relevant duties as assigned

• Associate s degree in Nursing
• Bachelor of Science Nursing degree preferred
• Registered licensed nurse (RN) required
• Strong clinical knowledge in respiratory failure, sepsis, CHF, ATN/CKD, and complex pneumonias required
• One-two years experience as CDI Specialists preferred
• 3M Coding and Reimbursement and/or 360 Encompass preferred
• Working knowledge of ICD-10 preferred
• Epic experience preferred

• Ability to achieve cognitive, organizational and emotional maturity to deal effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers
• Possesses interpersonal/communication skills necessary for effective, non-judgmental, and empathetic patient care and customer relations
• Open to feedback and open to a changing environment, which requires flexibility in scheduling and department assignments

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
• Centra State 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 All Spire 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…