Hospital CDI Specialist - PT - Day - Clinical Documentation Improvement Pennington NJ

Capital Health; New Jersey; On-site; USD 54,000 - 70,000; Full time

Benefits offered by this job

Retirement Savings and Investment Plan

Disability Benefits – STD

Sick Time Off

Employee Assistance Program

Job summary

Capital Health seeks a Clinical Documentation Specialist to improve the quality and completeness of clinical documentation across patient records, ensuring accurate DRG assignments and quality reporting. Strong communication with physicians and care teams is essential.

Two years of acute care experience or three years of coding/clinical documentation improvement in a hospital setting is required. CCDS or CDIP is preferred. Excellent documentation accuracy and collaboration are valued.

Qualifications

• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators.
• Excellent verbal and written communication skills.
• Working knowledge of all areas of adult medicine; knowledge of pathophysiology and disease processes.

Responsibilities

• Completes initial reviews of patient records within 24-48 hours of admission to evaluate documentation for accurate DRG assignment, risk of mortality, and severity of illness.
• Conducts follow-up reviews of patients every 2-3 days to support final DRG assignment at discharge.
• Queries physicians regarding missing or unclear documentation to obtain additional documentation.
• Educates physicians and healthcare providers regarding clinical documentation improvement and documentation guidelines.

Skills

Critical thinking

Verbal and written communication

EMR systems familiarity

Problem-solving

Education

RN license

BSN preferred

Tools

Windows-based software

Encoding software

EMR systems

Job description

Position Overview

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $51.47

Facilitates improvement of overall quality and completeness of clinical documentation in patient record through extensive interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff. Ensures that medical record documentation provides an accurate representation of the patient's clinical complexity, diagnoses, severity, and expected risk of mortality to support accurate DRG assignment and quality measure reporting. Maintains up-to-date knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Educates members of patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.

Minimum Requirements

Education: Graduate of an accredited school of nursing program. RN, required. BSN preferred. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) credential preferred.

Experience

Experience: Two years’ recent clinical experience in an acute care setting, preferable ICU or Medical/Surgical, or three years related coding experience or clinical documentation improvement specialist experience in a hospital setting.

Other Credentials

Other Credentials: Knowledge and Skills: Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues. Excellent verbal and written communication skills. Working knowledge of all areas of adult medicine. Knowledge of pathophysiology and disease process. Intermediate computer skills. Familiarity with windows-based software programs and encoding software. Special Training: Certification as CCDS or CDIP preferred. Mental, Behavioral and Emotional Abilities: Ability to work in environment using multiple EMR systems. Excellent observation, analytical thinking, and problem-solving skills. Ability to learn/develop skills necessary to perform CDI. Flexible, dependable and self-directed. Ability to work independently. Demonstrates ethical conduct.

Usual Work Day

Usual Work Day: 8 Hours

Reporting Relationships

Does this position formally supervise employees? No If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

Essential Functions

• Completes initial reviews of patient records within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness


• Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary


• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.


• Proactively identifies issues with reporting of diagnostic testing.


• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.


• Fosters teamwork and collaboration.


• Meets or exceeds departmental accuracy and productivity standards.


• Attends hospital or Medical Staff meetings to review or respond to documentation related issues.


• Provides technical assistance to the Medical Staff and patient care providers to efficiently navigate the electronic medical which could reside in multiple systems


• Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality


• Reviews and clarifies clinical issues in health record with coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.


• Facilitates change processes required to capture needed documentations, such as EMR template redesign


• Support pre-bill or post-bill reviews to address documentation gaps impacting reimbursement or quality measures.


• Maintains a level of expertise by attending continuing education programs.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Wrist position deviation , Pinching/fine motor activities Occasional physical demands include: Standing , Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl Continuous physical demands include: Sitting , Keyboard use/repetitive motion , Talk or Hear Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs. Sensory Requirements include: Accurate Near Vision, Minimal Hearing Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Chemical , Airborne Communicable Disease , Uneven Surfaces or Elevations , Dust/Particulate Matter

Benefits

• Retirement Savings and Investment Plan


• Disability Benefits – Short Term Disability (STD)


• Sick Time Off


• Employee Assistance Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.

Equal Opportunity Employer Notice Capital Health Benefits