Clinical Documentation Specialist

Job Description

Responsible for reviewing patient medical records throughout hospitalization to capture accurate representation of the severity of illness and facilitate proper coding. Validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.

• Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
• Creates job aids and queries in support of training initiatives.
• Ensures accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding.
• Discusses cases with physicians, including periodic meetings, rounding and/or attending medical staff meetings.
• Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured.
• Serves as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement efforts.
• Performs other relevant duties as assigned.

• Bachelor of Science Nursing degree preferred.
• Associate Degree in Nursing minimum required.
• 5 years of Med/Surg acute care clinical experience required, experience in ICU strongly preferred.
• Registered licensed nurse (RN) required.
• Strong clinical knowledge in respiratory failure, sepsis, CHF, ATN/CKD, and complex pneumonias required.
• One to two years experience as CDI Specialists preferred.
• 3M Coding and Reimbursement and/or 360 Encompass preferred.
• Working knowledge of ICD-10 preferred.
• Epic experience preferred.
• CCDS or CDIP certification referred to.

• Ability to achieve cognitive, organizational, and emotional maturity to effectively handle multiple tasks, stresses, deadlines, difficult situations, and/or customers.
• Possesses interpersonal/communication skills necessary for effective, non‑judgmental, and empathetic patient care and customer relations.
• Open to feedback and a changing environment, requiring flexibility in scheduling and department assignments.

• Medical, Dental, Vision, Prescription Coverage.
• Life & AD&D Insurance.
• Short‑Term and Long‑Term Disability.
• 403(b) Retirement Plan with Employer match.
• PTO & Paid Sick Leave.
• Tuition Assistance, Advancement & Academic Advising.
• Parental, Adoption, Surrogacy Leave.
• Backup and On‑Site Childcare.
• Well‑Being Rewards.
• Employee Assistance Program (EAP).
• Fertility Benefits, Healthy Pregnancy Program.
• Flexible Spending & Commuter Accounts.
• Pet, Home & Auto, Identity Theft and Legal Insurance.

Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran.