CDIS: Improve Documentation for Accurate Reimbursement

Cooper Norcross University Hospital; Cape May Court House (NJ); Remote; USD 47,000 - 77,000; Full time

Job summary

Cooper Norcross Health in Camden, NJ, is seeking a Clinical Documentation Specialist to review patient records and ensure accurate reflection of diagnoses, treatments, and illness severity. This role bridges clinicians and coders to support appropriate reimbursement and compliance.

Requirements include 3-5 years of experience, a high school diploma or GED, a bachelor’s degree, and Nursing background preferred; certifications in clinical documentation are a plus.

Qualifications

• 3-5 years of experience required.
• High School/GED Required.
• Bachelor's Degree Required.
• Bachelor's of Science in Nursing preferred.

Responsibilities

• Uses clinical expertise to review patient medical records and ensure that the documentation accurately reflects the patient’s diagnosis, treatments and severity of illness.
• 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 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.
• 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.

Skills

Medical records review

Documentation improvement

Clinical documentation quality

Communication

Education

High School/GED

Bachelor's Degree

Bachelor's of Science in Nursing

Job description

Cooper Norcross Health in Camden, NJ, is seeking a Clinical Documentation Specialist to review patient records and ensure accurate reflection of diagnoses, treatments, and illness severity. This role bridges clinicians and coders to support appropriate reimbursement and compliance.

Requirements include 3-5 years of experience, a high school diploma or GED, a bachelor’s degree, and Nursing background preferred; certifications in clinical documentation are a plus.