Clinical Documentation Improvement Lead

Cooper University Health Care; United States; Remote; USD 47,000 - 77,000; Full time

Job summary

Cooper Norcross Health, a leading academic health system, seeks a Clinical Documentation Specialist to review and refine patient records. You will bridge clinical documentation with coding, ensuring accurate reflection of severity and services across inpatient care.

Collaborate with HIM leadership and physicians to improve documentation quality, support appropriate reimbursement, and participate in education for clinicians and staff.

Qualifications

• Review patient medical records to ensure accurate reflection of diagnosis and treatments.
• Ensure inpatient records are consistent, legible and reflect severity of illness and services.
• Generate queries to clarify physician documentation when information is conflicting.
• Identify gaps in documentation and collaborate with physician advisor for clarification.
• Collaborate with HIM leadership and coders to improve DRG accuracy.
• Provide educational support to physicians, nurses and staff to improve documentation processes.
• Facilitate modifications to documentation to support appropriate reimbursement.
• Review cases denied for medical necessity to assist in appeals.

Responsibilities

• Review patient medical records for accuracy and completeness.
• Identify and document gaps in clinical information.
• Work with physician advisors to resolve inconsistencies.
• Support coding staff to improve final DRG accuracy.
• Educate clinicians on documentation best practices.
• Assist in post-review discussions to drive improvements.

Skills

Clinical documentation review

Medical record auditing

Communication skills

Education

High School/GED

Bachelor's Degree

Bachelor's of Science in Nursing (BSN) preferred

Job description

Cooper Norcross Health, a leading academic health system, seeks a Clinical Documentation Specialist to review and refine patient records. You will bridge clinical documentation with coding, ensuring accurate reflection of severity and services across inpatient care.

Collaborate with HIM leadership and physicians to improve documentation quality, support appropriate reimbursement, and participate in education for clinicians and staff.