St Josephs Healthcare System

Clinical Documentation Specialist

Requisition ID
2017-10685
Shift
Day
Category
Nursing
Shift Hours AM/PM
8:00AM-4:30PM
Department
SJ HR
Position Type
Regular Full-Time

Overview

Responsible for reviewing medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program®  (CDMP®) documentation strategies.  Reviews and recommends opportunities for documentation improvement.  Requires extensive record review, interaction with physicians, Health Information Management professionals, Care Management and nursing staff.  Actively participation in team meetings and education of staff.

Responsibilities

Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program®  (CDMP®) documentation strategies.  Initiates CDMP® severity worksheet for inpatients. Reviews and recommends opportunities for documentation improvement. Formulate clinically credible documentation clarifications. Requests documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety. Timely follows up on all cases and resolution of those with clinical documentation clarifications. Communicates with appropriate staff and resolves discrepancies. Modifies practice to incorporate changes in regulatory and coding guidelines. Coordinates and consults with Medical Director, Medical Staff, and Care Management Director. Participates in Task Force Meetings and attends Clinical Resource Utilization Committee, as needed. Meets all required competencies for department, unit and/or hospital. Responsible for performing all other duties as assigned.

Qualifications

Work requires the knowledge of theories, principles and concepts normally acquired through completion of a Bachelor's degree in Nursing or closely related filed, Masters degree preferred, and three to five years of previous work related experience  in Medical/Surgical, Intensive Care, Emergency Department, or PACU.  Coding or billing experience preferred.  Licensure required as a Registered Nurse by the State of New Jersey.  Excellent writing, speaking and communication skills.  Ability to prioritize and manage multiple projects simultaneously. Ability to work effectively with a wide range of hospital, professional, corporate and community constituencies.

Options

Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
Share