Clinical Documentation Improvement Specialist

Cooper University Health Care; Camden (NJ); On-site; USD 65,000 - 97,000; Full time

Benefits offered by this job

Employee benefits program

On-site Early Education Center

Employee discount

Job summary

Cooper University Health Care seeks a CDI Specialist to review inpatient medical records, generate queries, and bridge documentation gaps with physician input. You will collaborate with HIM leadership, coders, and educators to improve DRG accuracy and support appropriate reimbursement.

The role emphasizes education of clinicians and concurrent documentation enhancements across departments to ensure compliant, complete medical records.

Qualifications

• Review inpatient medical records for accuracy and legibility reflecting illness severity and services.
• Generate queries to clarify conflicting or incomplete documentation.
• Identify gaps in clinical documentation and bridge with physician advisor input.

Responsibilities

• Collaborate with HIM Leadership, Coders, and educators to improve DRG accuracy.
• Educate physicians, nurses, and staff to modify documentation processes for appropriate reimbursement.
• Provide clinical review of cases denied for medical necessity and assist with appeals.

Skills

Clinical documentation

Medical records review

Query generation

Education

Bachelor of Science in Nursing

CDI experience

Tools

HIM leadership collaboration

Job description

About Us

Cooper University Health Care is an integrated healthcare delivery system serving residents and visitors throughout Cape May County. The system includes Cooper University Hospital Cape Regional; three urgent care facilities; nearly 30 primary care and specialty care offices in multiple locations throughout Cape May County; The Cancer Center at Cooper University Hospital Cape Regional; the Claire C. Brodesser Surgery Center; AMI at Cooper, Miracles Fitness and numerous freestanding outpatient facilities providing wound care, lab, and physical therapy services. We have a commitment to our employees by providing competitive rates and compensation programs. Cooper offers full and part time employees a comprehensive employee benefits program, including health, dental, vision, life, disability, retirement, on-site Early Education Center (employee discount), attractive working conditions, and the chance to build and explore a career opportunity by offering professional development.

Short Description

• 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.

Education Requirements

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

Salary Min ($)

USD $46.87

Salary Max ($)

USD $70.31