Clin Documentation Spec III

About Us

AtCooper University Health Care, our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees to provide competitive rates and compensation programs. Cooper offers full and part-time employees a comprehensive benefits program, including health, dental, vision, life, disability, and retirement. We also provide attractive working conditions and opportunities for career growth through professional development.

Discover why Cooper University Health Care is the employer of choice in South Jersey.

Short Description

• Responsible for ensuring the overall quality and completeness of medical record documentation.
• 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.
• Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
• Educates all members of the patient care team on an ongoing basis.
• Professional team player, able to communicate well with others on all levels.
• Regular significant contacts with other personnel throughout and outside the hospital.
• Contacts may be in person, by telephone or-through correspondence.
• Flexible with a working knowledge of all areas of adult medicine.
• Occasional lifting/carrying up to fifteen pounds, as well as reaching, stretching, stooping, bending, kneeling, crouching, standing, walking and pushing/pulling to move and file medical records alone or in carts.
• Ability to sit for long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer and other office equipment.
• Adequate to perform essential functions of the job with the type of judgments and potential consequences outlined above.

Experience Required

• EPIC EHR
• CDE ONE, Solventum
• 5 years minimum experience as Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center.
• CDI Subject matter expert for ALL PAYORS, all DRG groups (MS-DRG, APR-DRG, AP-DRG Elixhauser, risk variables)
• PSI/HAC/HCC (Risk adjustment coding) knowledge/experience and Vizient Calculator

Education Requirements

Registered Nurse, any state. BSN or higher preferred or International medical graduate.

License/Certification Requirements

• CCDS or CDIP
• Registered Nurse, any state. BSN or higher preferred
• Coding certification: CCS or CRC; CIC is an acceptable equivalent

Special Requirements

Essential mental abilities: excellent critical thinking skills, able to assess, evaluate and teach. Must be self governed, disciplined, and organized.

Requires excellent work ethic, analytical thinking, problem solving, excellent computer skills, excellent verbal and written communication with knowledge of email etiquette. Must be proficient in Word, Excel, PowerPoint and typing (60 WPM)

Salary Min ($)

USD $41.00

Salary Max ($)

USD $70.00

Originally posted on Himalayas