CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST - REMOTE

Cooper Norcross Health; Cape May Court House (NJ); Remote; USD 70,000 - 90,000; Full time

Job summary

Cooper Norcross Health seeks a Clinical Documentation Specialist to review patient records for accurate diagnoses and severity, bridging clinicians and coders to ensure complete, compliant documentation.

Responsibilities include concurrent chart reviews, query generation, gaps analysis, and collaboration with the HIM leadership and physicians to improve documentation quality for proper reimbursement.

Qualifications

• 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.

Responsibilities

• Review patient records for accurate reflection of diagnosis and severity of illness.
• Identify gaps in documentation and generate queries to physicians for clarification.
• Collaborate with HIM leadership and coding staff to improve final DRG accuracy.
• Educate clinicians on documentation best practices to support appropriate reimbursement.

Skills

Team player

Communication skills

Education

High School/GED

Bachelor's Degree

Bachelor's of Science in Nursing

Job description

About us

Cooper Norcross Health, formerly Cooper University Health Care, is a leading academic health system affiliated with Cooper Medical School of Rowan University. Headquartered in Camden, New Jersey, Cooper Norcross Health has revenues of more than $3 billion and an A+ credit rating from both S&P and Fitch Ratings.

Cooper Norcross Health has nearly 14,000 team members, including more than 2,200 nurses, more than 1,200 employed physicians representing 95 specialties and subspecialties, and more than 700 advanced practice providers.

The health system operates MD Anderson Cancer Center at Cooper as well as four hospitals – its 663-bed flagship Cooper Norcross University Hospital in Camden, its 229-bed Cooper Norcross University Hospital Cape Regional in Cape May Court House, Children’s Hospital at Cooper Norcross Health in Camden, and The Recovery Village Cherry Hill at Cooper, a substance abuse rehabilitation and inpatient treatment facility, in partnership with Advanced Recovery Systems.

Cooper Norcross University Hospital in Camden is the only Level 1 Trauma Center in South Jersey and the busiest in the region. The hospital has been recognized as a top-performing regional hospital by U.S. News & World Report’s Best Hospitals annual survey for eight years.

More than 2.54 million patients visit Cooper Norcross Health facilities annually. Its ambulatory network encompasses three outpatient surgery centers, seven urgent care centers, a wound care center, and more than 130 physician, physical therapy, and radiology offices extending from the Delaware River to the New Jersey shore.

Cooper Norcross Health, a not-for-profit health system, was named one of America’s Best Large Employers for 2026 by Forbes, ranking among the top 200 in the nation. Visit CooperHealth.org to learn more.

Short Description

• Uses clinical expertise to review patient medical records and ensure that the documentation accurately reflects the patient’s diagnosis, treatments and severity of illness. This role bridges the gap between healthcare providers and coding professionals, ensuring that medical records are complete, compliant, and support proper reimbursement.
• 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.

Experience Required

3-5 years of experience required.

Education Requirements

• High School/GED Required
• Bachelor's Degree Required
• Bachelor's of Science in Nursing preferred

License/Certification Requirements

• Certified Clinical Documentation Specialist Certification preferred
• Certified Documentation Improvement Practitioner preferred
• Registered Nurse, any state, preferred

Special Requirements

Professional team player, able to communicate well with others on all levels required.