CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST

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

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.