Clinical Documentation Specialist

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National Coalition of Healthcare Recruiters
Job Overview

(Only QUALIFIED Healthcare Professionals accepted) Immediate need for a Clinical Documentation Specialist!!!

Do you have an RN or are you an MD?

Located 20 Minutes from the Jersey Shore in a Quiet, Thriving Suburban Setting

Good schools and a variety of housing options make this location a great place to raise a family

I have a CDI Position with a wonderful Magnet Status Acute-Care Hospital ! I’d love to help you further your career by joining a team like this. There is 1 Opening for an experienced Clinical Documentation Specialist.



Job description:

The Clinical Documentation Improvement Specialist (CDIS) will perform concurrent analytical review of clinical and coding data with a goal of improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, severity of illness & risk of mortality profiling, and reimbursement.


Educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians, allied health practitioners, nursing, and case management.
Facilitates and obtains appropriate physician documentation including resolution of queries for any clinical conditions or procedures.
Performs concurrent analytical review of clinical and coding data with a goal of improving physician documentation for all conditions and treatments.
Facilitates concurrent modifications to clinical documentation to support care provided.
Conducts follow-up documentation reviews to ensure clarification has been recorded in the patient’s chart.
Reviews clinical issues with coding staff, nurses and others to ensure appropriate inpatient technical diagnosis and procedural coding.
Seeks opportunities to discuss cases with physicians/providers at meetings, rounding and medical staff meetings.
Maintains a collaborative working relationship with quality, case management and HIM staff.
Inputs activities from concurrent reviews into CDI software and ensures consistency of data captured.
Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission.



Qualifications:


BSN
Current NJ RN License required
2 years of Clinical Experience In A Healthcare Environment Required
1 year of Coding Experience a plus
Possession of Certified Coding Specialist designation (CCS, CSS, CCS-P from AHIMA) a plus














Preferred: Prior CDI experience in 200+ bed acute care hospitals.

Preferred: CCDS OR CDIP

Call Julia at 513-259-2250
AND/OR Email resume to: Jlutz@acuitymri.com

Job Detail
  • Job IDnchcr-1927861
  • StreetN/A
  • StateNew Jersey
  • Postal CodeN/A
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