Hospital CDI Specialist - PT - Day - Clinical Documentation Improvement Pennington NJ

Position Overview

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range: $39.40 - $51.47

Facilitates improvement of overall quality and completeness of clinical documentation in patient record through extensive interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff. Ensures that medical record documentation provides an accurate representation of the patient's clinical complexity, diagnoses, severity, and expected risk of mortality to support accurate DRG assignment and quality measure reporting. Maintains up-to-date knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures.

Educates members of patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.

Education:

Graduate of an accredited school of nursing program. RN, required. BSN preferred. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) credential preferred.

Experience:

Two years’ recent clinical experience in an acute care setting, preferable ICU or Medical/Surgical, or three years related coding experience or clinical documentation improvement specialist experience in a hospital setting.

Other Credentials:
Knowledge and

Skills:

Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues. Excellent verbal and written communication skills. Working knowledge of all areas of adult medicine. Knowledge of pathophysiology and disease process. Intermediate computer skills. Familiarity with windows-based software programs and encoding software. Special Training:
Certification as CCDS or CDIP preferred. Mental, Behavioral and Emotional Abilities:
Ability to work in environment using multiple EMR systems. Excellent observation, analytical thinking, and problem-solving skills. Ability to learn/develop skills necessary to perform CDI. Flexible, dependable and self-directed. Ability to work independently. Demonstrates ethical conduct.

Usual Work Day: 8 Hours

Does this position formally supervise employees? No If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

• Completes initial reviews of patient records within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness
• Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
• Proactively identifies issues with reporting of diagnostic testing.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Fosters teamwork and collaboration.
• Meets or exceeds departmental accuracy and productivity standards.
• Attends hospital or Medical Staff meetings to review or respond to documentation related issues.
• Provides technical assistance to the Medical Staff and patient care providers to efficiently navigate the electronic medical which could reside in multiple systems
• Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality
• Reviews and clarifies clinical issues in health record with coding professionals that would support an accurate DRG…