Clinical Documentation Specialist
Job ID: 19NSH97079
Jul 10 (156d ago)
Health Information Management
PS-30S: Min:$74,404.00 Mid. $89,926.00 Max. $107,295.00
Currently licensed as a Registered Nurse in the State of New Jersey. Bachelor’s Degree, plus a minimum of three (3) years recent experience in a clinical setting, preferably in an acute care setting, required. Foreign medical graduates with relevant clinical documentation improvement experience will be considered in lieu of RN licensure and RN experience. Equivalent experience, education and/or training may be substituted for the education or experience requirements. Two to three (2 or 3) years of prior experience as Clinical Documentation Specialist in a hospital setting preferred; CCDS, C-CDI highly desirable. Coding or abstracting experience in ICD-9-CM with data management responsibilities a plus. Strong interpersonal skills, verbal and written communication skills and small group presentation skills needed. Demonstrates professionalism, tact and diplomacy when working with the medical staff, outside organizations and other hospital departments. Must be able to fluently read and speak English and possess excellent written communication skills. Must be able to read clinical staff handwriting within medical record. Must be detail-oriented, accurate, organized, productivity-driven and work independently. Excellent PC application skills (Word, Excel, PowerPoint-minimum).
The primary purpose of the Clinical Documentation and Coding Integrity (CDCI) Specialist position is to review clinical documentation both concurrently and retrospectively for opportunities to improve physician documentation. The CDCI Specialist will ensure that the medical record documentation provides an accurate representation of the patient's clinical care, diagnosis, and severity. The CDCI Specialist will facilitate accurate clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer, and to ensure the accuracy of clinical information used for measuring and reporting physician and facility performance outcomes.
University Hospital offers a competitive salary & comprehensive benefits package. Affirmative Action/Equal Opportunity Employer, M/F/D/V. For more information, visit www.uhnj.org/hrweb.