[Hiring] Clinical Documentation Improvement Specialist @Cooper Norcross University Hospital

Role Description

Uses clinical expertise to review patient medical records and ensure that the documentation accurately reflects the patient’s diagnosis, treatments and severity of illness. This role bridges the gap between healthcare providers and coding professionals, ensuring that medical records are complete, compliant, and support proper reimbursement.

• Concurrently review inpatient medical records for clear, consistent, concise, legible, and accurate documentation to reflect the patient’s severity of illness and intensity of services.
• Generate and utilize queries to clarify physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure.
• Complete analysis of clinical information to identify gaps in clinical documentation. To “bridge the gap,” utilize the physician advisor for clarification of clinical presentation.
• Collaboratively work with HIM Leadership, Coders, Coding Quality Educators/Reviewers, and peers to improve accuracy of final DRG.
• Collaborate and provide educational support to physicians, nurses, and ancillary staff to facilitate modifications of clinical documentation processes that promote documentation improvement.
• Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregivers, and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients.
• Provide clinical review of cases denied for medical necessity by auditing agencies. Using knowledge of medical necessity criteria, assist physician advisor in collecting pertinent information to support an appeal.

Qualifications

• 3-5 years of experience required.

Requirements

• High School/GED Required
• Bachelor's Degree Required
• Bachelor's of Science in Nursing preferred

License/Certification Requirements

• Certified Clinical Documentation Specialist Certification preferred
• Certified Documentation Improvement Practitioner preferred
• Registered Nurse, any state, preferred

Special Requirements

• Professional team player, able to communicate well with others on all levels required.

Salary

• Salary Min: USD $34.00
• Salary Max: USD $56.00