CDI Specialist: Elevate Documentation & Reimbursement

Cooper University Health Care; Camden (NJ); On-site; USD 80,000 - 120,000; Full time

Benefits offered by this job

Health benefits

Dental insurance

Vision care

Retirement plan

On-site Early Education Center

Job summary

Cooper University Health Care is seeking a Clinical Documentation Improvement professional to review inpatient records for accurate documentation reflecting illness severity and services provided. You will generate queries to clarify ambiguous entries and bridge gaps with physician advisors.

Collaborating with HIM leaders and coders, you will help improve final DRG accuracy and educate physicians, nurses and staff to enhance documentation processes and reimbursement outcomes.

Qualifications

• Bachelor of Science in Nursing preferred; however, candidates with any bachelor’s degree will be considered if they have CDI experience.

Responsibilities

• Concurrently review inpatient medical records for clear, consistent, concise, legible and accurate documentation to reflect the patient’s severity of illness and intensity of services.
• Generate and utilize queries to clarify physician documentation whenever there is conflicting, ambiguous or incomplete information in the medical record regarding any significant reportable condition or procedure.
• Complete analysis of clinical information to identify gaps in clinical documentation. To bridge the gap, utilize the physician advisor for clarification of clinical presentation.
• Collaboratively work with HIM Leadership, Coders, Coding Quality Educators/Reviewers and peers to improve accuracy of final DRG.
• Collaborate and provide educational support to physicians, nurses and ancillary staff to facilitate modifications of clinical documentation processes that promote documentation improvement.
• Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregivers and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients.
• Provide clinical review of cases denied for medical necessity by auditing agencies. Using knowledge of medical necessity criteria assist physician advisor in collecting pertinent information to support an appeal.

Education

Bachelor of Science in Nursing preferred; however, candidates with any bachelor’s degree will be considered if they have CDI experience.

Job description

Cooper University Health Care is seeking a Clinical Documentation Improvement professional to review inpatient records for accurate documentation reflecting illness severity and services provided. You will generate queries to clarify ambiguous entries and bridge gaps with physician advisors.

Collaborating with HIM leaders and coders, you will help improve final DRG accuracy and educate physicians, nurses and staff to enhance documentation processes and reimbursement outcomes.