Clinical Documentation Improvement Specialist

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🔥 19 hours ago

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $34 - $56 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Cooper University Hospital

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1 - 1 employees

🏥 Healthcare

📚 Education

Healthcare • Education

Cooper University Hospital is an academic medical center and the flagship hospital of Cooper Norcross Health (formerly Cooper University Health Care). It provides inpatient and outpatient care across a wide range of specialties and subspecialties, operates regional centers and programs (including the MD Anderson Cancer Center at Cooper), and emphasizes education and research through graduate medical education, academic departments, and clinical trials. The system serves the South Jersey and Philadelphia metro region with dozens of locations, hundreds of clinicians, and community-facing services such as interpreter services, financial assistance, and classes and events.

📋 Description

• Review inpatient medical records concurrently to ensure clear, consistent, concise, legible, and accurate documentation reflecting patients’ severity of illness and intensity of services • Generate and utilize queries to clarify physician documentation when medical records contain conflicting, ambiguous, or incomplete information about significant reportable conditions or procedures • Analyze clinical information to identify gaps in clinical documentation • Utilize the physician advisor to clarify clinical presentation • Collaborate with HIM Leadership, coders, Coding Quality Educators/Reviewers, and peers to improve final DRG accuracy • Provide educational support to physicians, nurses, and ancillary staff to improve clinical documentation processes • Facilitate documentation modifications through interaction with physicians, nursing staff, caregivers, and Health Information coding staff to capture appropriate reimbursement and clinical severity • Review cases denied for medical necessity by auditing agencies and assist the physician advisor with appeals by collecting pertinent information

🎯 Requirements

• 3-5 years of experience required • High School/GED Required • Bachelor's Degree Required • Certified Clinical Documentation Specialist Certification preferred • Certified Documentation Improvement Practitioner preferred • Registered Nurse, any state, preferred • Professional team player, able to communicate well with others on all levels required

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