Clinical Documentation Improvement Lead

COOPER PEDIATRICS; Camden (NJ); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health benefits

Dental benefits

Vision benefits

Life insurance

Retirement plan

Professional development

Job summary

Cooper University Health Care is seeking a CDI-focused professional to review inpatient records and improve documentation. You will query unclear information, collaborate with HIM leadership and coders, and educate staff to ensure accurate severity and reimbursement.

The role emphasizes working with physician advisors, bridging documentation gaps, and supporting appeals for denials when necessary. A BSN is preferred, with CDI experience guiding the selection.

Qualifications

• BSN preferred; candidates with a different degree may be considered if CDI experience is shown.
• CDI experience required or preferred to support documentation improvement.
• Inpatient records review and accurate severity documentation are essential.

Responsibilities

• Concurrently review inpatient medical records for clarity and accuracy reflecting severity of illness and services.
• Generate and utilize queries to clarify documentation when information is conflicting or incomplete.
• Analyze clinical information to identify gaps and bridge with physician advisor for clarification.
• Collaborate with HIM Leadership, Coders, and educators to improve DRG accuracy.
• Provide educational support to physicians, nurses, and staff to improve documentation processes.
• Facilitate documentation updates to ensure appropriate reimbursement and clinical severity capture.
• Review cases denied for medical necessity and assist in collecting information to support appeals.

Skills

CDI experience

Healthcare documentation

Education

Bachelor of Science in Nursing

Job description

Cooper University Health Care is seeking a CDI-focused professional to review inpatient records and improve documentation. You will query unclear information, collaborate with HIM leadership and coders, and educate staff to ensure accurate severity and reimbursement.

The role emphasizes working with physician advisors, bridging documentation gaps, and supporting appeals for denials when necessary. A BSN is preferred, with CDI experience guiding the selection.