Clinical Documentation Specialist RN

Clinical Documentation Specialist RN

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Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.

Together, we keep getting better — advancing our mission to transform healthcare and serve as a leader of positive change.

The Clinical Documentation Specialist RN facilitates improvement in the overall quality, completeness and accuracy of medical record documentation for assigned hospitals of Hackensack Meridian Health. The role obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department, to ensure documentation reflects the level of service rendered to patients is complete and accurate.

The specialist educates the patient care team on documentation guidelines on an ongoing basis. The specialist reviews and screens ED inpatient admissions and observations as specified by the facility’s Utilization Management/Review Committee for documentation completeness and compliance with patient status. The specialist facilitates accurate documentation for severity of illness and medical necessity, interacts with physicians, case managers, and nursing staff, and provides guidance and recommendations for admission or observation disposition.

The specialist assesses patients for present‑on‑admission (POA) conditions to ensure accurate documentation regarding hospital‑acquired conditions (HAC). The specialist communicates the transfer of appropriate concurrent information to the inpatient case managers and the Clinical Documentation Specialists assigned to the unit.

• 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 the medical screening process by documenting appropriate 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 requests for documentation have 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 the patient’s chart.
• As appropriate, documents and analyzes data and reports 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.
• Collabo…