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CareWell Health Medical Center · 1 month ago

Clinical Documentation Specialist

East Orange, NJ

Full-time

Onsite

Entry, Mid Level

2+ years exp

CareWell Health Medical Center is focused on improving clinical documentation quality and accuracy. The Clinical Documentation Specialist will conduct comprehensive reviews of clinical documentation, collaborate with healthcare staff, and educate providers to ensure compliance and proper reimbursement for services rendered.

Health Care

Responsibilities

Conducts concurrent, retrospective and post-bill comprehensive reviews of the clinical documentation

Facilitates modifications updates to the clinical documentation to ensure appropriate reimbursement for the level of service provided to all patients with a DRG based payer

Demonstrates knowledge of DRG payer issues, documentation opportunities, and clinical documentation requirements

Improves the overall quality and completeness of clinical documentation by performing detailed concurrent, retrospective and post-bill reviews of the clinical documentation for quality improvement and financial impact on Inpatients

Improves the entire documentation for Severity of Illness, Risk of Mortality, Acuity and to capture Comorbid and Major Comorbid conditions

Ensures details are elaborated on within the physician queries to ensure they are compliant and complete by including clinical indicators, treatment and documentation

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and organizational outcomes

Collaborates with Case Management, and Nursing to ensure the level of care provided to the patients is accurately reflected in the documentation and meets quality and compliance goals set forth by the facility

Places timely queries into the Electronic Medical Record to capture any changes in status, procedures/ treatments as set forth by CareWell Health's Policies and Procedures

Follows up on unanswered queries, in a timely manner by contacting the provider and conferring with physician to finalize diagnoses

Educates all relevant internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies

Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s medical record

Identify gaps, inconsistencies, or omissions in documentation that impact coding, severity of illness (SOI), risk of mortality (ROM), and quality metrics

Act as a liaison between clinical and coding teams to ensure consistent documentation and coding practices

Participate in quality improvement initiatives, audits, and committee work

Stay current with CDI best practices, coding guidelines (ICD-10, MS-DRG, APR-DRG), and regulatory changes (CMS, OIG, etc.)

Must be computer savvy

Assists with special projects

Provides CDI Metric Reporting and program updates to the Utilization Review Committee, when necessary

Advises CDI Manager and/or Director of HIM with immediate challenges that have a negative impact on the program’s functions

Performs other duties as assigned

Qualification

Clinical Documentation ImprovementICD-10 CodingCertified Coding SpecialistRegistered NurseCritical ThinkingAnalytical ThinkingCommunication SkillsInterpersonal SkillsProblem Solving

Required

Certified Coding Specialist (CCS), required

Certified Clinical Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS), required or obtained within one (1) year of employment

Registered Nurse (RN), MD, DO, or ECFMG Certification, required

Two (2) years of CD experience in an acute care hospital and / or 2 (two) years of ICD-10 CM coding experience

Strong critical thinking skills, able to assess, evaluate and teach

Flexible with a working knowledge of adult medicine

Requires excellent observation skills, analytical thinking, problem solving, good strong verbal and written communication skills

Professional, team player, able to communicate well with all levels of staff

Strong interpersonal skills, pleasing personality, positive demeanor