Clinical Documentation Specialist (8am - 4:30pm)

Requisition ID
2017-10688
Shift
Day
Category
Nursing
Shift Hours AM/PM
8:00AM-4:30PM
Department
SJ HR
Position Type
Regular Full-Time

Overview

St. Joseph’s Healthcare System is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization’s outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation’s “100 Best Places to Work in Health Care”.

 

Job 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.  Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.  Educates all members of the patient care team on an ongoing basis.

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 Director, Health Information Management.          
  • Participates in Task Force meetings, TRAK sessions, and attends CDMP Steering Committee meetings, 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, Master's degree preferred OR completion of a Doctorate from a Medical or Osteopathic college.  Five years of recent clinical experience in an acute, adult hospital with in-patient, medical/surgical, emergency room, and/or a critical care setting. CDI (Clinical Documetation Improvement) experience preferred.  Licensure required as a Registered Nurse by the State of New Jersey OR licensure required as a Medical Doctor 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.

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