Job Description

Overview

1. 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.
2. 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.
3. Will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels.

Responsibilities

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.

1. Completes the initial review within 24-48 hours of admission.

2. Completes concurrent reviews to ensure working DRG, SOI and ROM and all
comorbid conditions are documented by the providers to the greatest specificity

3. 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.
1. Follows each query through to closure including complete documentation of ongoing follow up
2. 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

Qualifications

Licensed Registered Nurse credentialed from theNJ Board of Nursing

Minimum of three years of experience preferred in the acute-care setting in: surgical, intensive care, emergency medicine preferred. An advanced understanding of anatomy, physiology, pathophysiology and pharmacology

Preferred prior CDI experience.

CCDS or CDIP preferred

About Us

Atlantic Health System aims to deliver the highest quality, safety and care combined the best experience for our patients and their families. We are confident that you will find success within Atlantic Health System, which has been named for the 14th year in a row to Fortune’s “Top 100 Best U.S. Companies to Work For” list. We believe you will find that our culture of collaboration and care exemplifies the value we place on our patients, their families and our employees.

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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