JFK Johnson Rehabilitation Institute · 18 hours ago
CLINICAL DOCUMENTATION SPECIALIST
Hackensack, NJ
Part-time
Onsite
Senior Level
$48K/yr - $48K/yr
5+ years expHackensack Meridian Health is dedicated to transforming healthcare and serving as a leader of positive change. The Clinical Documentation Specialist facilitates improvement in the quality and accuracy of medical record documentation, ensuring that clinical documentation reflects the services rendered to patients. This role involves extensive interaction with healthcare staff and educating them on documentation guidelines.
Hospital & Health Care
Responsibilities
Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record
Performs admission reviews for specific patient populations using clinical documentation guidelines
Assists in medical screening process by documenting appropriateness of patient admission, working DRG & LOS information on worksheet and computer system as appropriate
Extensively reviews all physician and clinical documentation, lab results, diagnostic information and treatment plans and captures appropriate information on CDMP® / 3M 360 worksheet
Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption
Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified
Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities
Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses
Reviews medical record every 24-48 hours as appropriate
Updates CDMP® / 3M 360 worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate
Updates CDMP® / 3M 360 worksheet to reflect any changes in DRG and/or APR assignment
Communicates with physician to ensure that request for documentation has been noted
Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures
Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient's chart
As appropriate, documents and analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Director of Health Information
Follows established CDMP® process for follow-up reviews and physician communication
Reviews clinical issues with coding staff to assign working DRG using software
Collaborates with coding staff as needed to determine appropriate DRG and required documentation
Utilizes coding staff knowledge of Coding Clinics that impact CDMP®
Provides clinical expertise and references to the coding staff
Follows established guidelines for reconciling final coded DRG with the CDMP® DRG assigned at the time of discharge
Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance
Attends and participates in weekly educational conferences
Participates in concurrent performance improvement activities and on-going MR review activities
Reviews CDMP® / 3M 360 tracking data in conjunction with established benchmarks
Provides overview of CDMP® to new staff, allied health professionals and physicians
Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Coding Compliance Manager, Department Director and Emergency Trauma Dept
Screens ED inpatient admissions and observations determining the necessity and appropriateness of hospitalizations using facility criteria
Recommends admission or observation disposition to the ED physician in accordance to the screening
Collaborates with admitting physician to place patient in appropriate status
CDS must attend/participate in Multidisciplinary Rounds (MDR) of their designated/assigned unit
Communicates with physician when screening criteria is not met for inpatient and requests additional documentation if appropriate
Reviews medical record for completeness and accuracy for severity of illness (SOI) using the Compliant Documentation Management Program® (CDMP®) documentation strategies
Initiates CDMP® / 3M 360 severity worksheet for inpatients
Requests documentation clarification as appropriate for SOI
Assesses all appropriate admissions for POA documentation of: a. Pressure ulcers. b. Vascular-catheter associated infections. c. Indwelling urinary catheter associated infections. d. Surgical Site infection (mediastinitis). e. DVT, Pulmonary embolus. f. Risk for falls
Documents assessments in the medical record
Initiates core measure review as indicated for specific clinical topics: a. AMI. b. Pneumonia. c. Heart Failure d. Stroke e. Severe Sepsis & Septic Shock f. Upon identification of Core Measures, follow and adhere to CDMP® Core Measures protocols. g. Upon identification of Patient Safety Indicators (PSIs), follow PSI flowsheet and adhere to CDMP® protocols
Provides ongoing education to ED and admitting physicians regarding appropriate documentation and criteria for admission, observation, and level of care to comply with federal and state mandates. Uses Milliman and Medicare and other appropriate resources
Maintains liaison with the inpatient case manager and communicates necessary follow up
Maintains liaison with inpatient CDS and provides report summary
Performs other related job duties as requested
Adheres to HMH Organizational competencies and standards of behavior
Qualification
Required
Graduation from medical school
Minimum of 5 or more years of experience reviewing and screening inpatient admissions and observations or equivalent experience
Experience assessing patients and improving the quality and ensuring compliance of medical records documentation or equivalent experience
Ability to interact well with physicians and other members of allied health care team, including HIM coders
Must be computer literate, have working knowledge and familiarity of Microsoft Word and Excel/Windows based software programs
Must possess excellent communication, organizational, analytical, writing and interpersonal skills
Dependable, self-directed and pleasant
Critical thinking, problem solving and deductive reasoning skills
Recent hospital experience
Knowledge of Pathophysiology and Disease Process
Knowledge of Medicare Part A
Familiar with Medicare Part B
Knowledge of regulatory environment
Understand and support CDMP® documentation strategies
Knowledge of POA/HAC and core measures
Knowledge of Observation and Inpatient medical necessity
Knowledge of regulatory requirements for appropriateness of admissions
Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility
Preferred
ICU, CCU and/or strong Medical/Surgical experience
Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility
Benefits
Health, dental, vision, paid leave, tuition reimbursement, and retirement benefits
Company
JFK Johnson Rehabilitation Institute
Offering New Jersey’s most comprehensive rehabilitation services, JFK Johnson Rehabilitation Institute is a 94-bed facility located in Edison, NJ, serving residents of the tristate area for more than 40 years.
10001+ employees
Funding
Current Stage
Late StageCompany data provided by crunchbase