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Clin Documentation Spec III, RN & Coding Certification Required
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About the position
At Cooper University Health Care , our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees to provide competitive rates and compensation programs. Cooper offers full and part-time employees a comprehensive benefits program, including health, dental, vision, life, disability, and retirement. We also provide attractive working conditions and opportunities for career growth through professional development. Discover why Cooper University Health Care is the employer of choice in South Jersey. Short Description This is a remote position. You must self provide high speed internet access and a phone line. Depending on shortages, you may be required to self-provide additional monitors (you will need to work on a minimum of 2 monitors). This job does not require any travel. Responsible for ensuring the overall quality and completeness of medical record Documentation for all payor groups, all DRG’s, including MS, AP, and APR. Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes Educates all members of the patient care team on an ongoing basis, as needed. Professional team player, able to communicate well with others on all levels. Regular electronic contacts with other personnel throughout and outside the hospital Contacts may be in by telephone or through e-mail correspondence. Flexible with a working knowledge of all areas of adult medicine. Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer and other office equipment. Adequate to perform essential functions of the job with the type of judgments and potential consequences outlined above.
Responsibilities
Responsible for ensuring the overall quality and completeness of medical record Documentation for all payor groups, all DRG’s, including MS, AP, and APR.
Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients.
Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes
Educates all members of the patient care team on an ongoing basis, as needed.
Professional team player, able to communicate well with others on all levels.
Regular electronic contacts with other personnel throughout and outside the hospital Contacts may be in by telephone or through e-mail correspondence.
Flexible with a working knowledge of all areas of adult medicine.
Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer and other office equipment.
Adequate to perform essential functions of the job with the type of judgments and potential consequences outlined above.
Requirements
EPIC EHR
Clintegrity CDE software
5 years minimum experience as Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center.
CDI Subject matter expert for ALL PAYORS, all DRG groups (MS-DRG, APR-DRG, AP-DRG)
