CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST

About Us

Cooper University Health Care is an integrated healthcare delivery system serving residents and visitors throughout Cape May County. The system includes Cooper University Hospital Cape Regional; three urgent care facilities; nearly 30 primary care and specialty care offices in multiple locations throughout Cape May County; The Cancer Center at Cooper University Hospital Cape Regional; the Claire C. Brodesser Surgery Center; AMI at Cooper, Miracles Fitness and numerous freestanding outpatient facilities providing wound care, lab, and physical therapy services.

Responsibilities

• 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. Use the physician advisor for clarification of clinical presentation to “bridge the gap.”
• 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.
• Facilitate modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregivers, and Health Information coding staff to ensure 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 the physician advisor in collecting pertinent information to support an appeal.

Requirements

• Bachelor of Science in Nursing preferred; however, candidates with any bachelor’s degree will be considered if they have CDI (Clinical Documentation Improvement) experience.

Benefits

Cooper offers full and part-time employees a comprehensive employee benefits program, including:

• Health, dental, vision, life, and disability insurance
• Retirement plans
• On-site Early Education Center (employee discount)
• Attractive working conditions
• Professional development opportunities