The Clinical Documentation Improvement Specialist (CDIS) will perform concurrent analytical review of clinical and coding data with a goal of improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, severity of illness & risk of mortality profiling, and reimbursement. The CDIS will facilitate the resolution of queries as well as educate members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians, allied health practitioners, nursing, and case management. Finally, the CDIS will collaborate with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
- Collaborates with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
- Educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians, allied health practitioners, nursing, and case management.
- Facilitates and obtains appropriate physician documentation including resolution of queries for any clinical conditions or procedures.
- Performs concurrent analytical review of clinical and coding data with a goal of improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, severity of illness and risk of mortality profiling, and reimbursement.
- Facilitates concurrent modifications to clinical documentation to support care provided.
- Conducts follow-up documentation reviews to ensure clarification has been recorded in the patient’s chart.
- Reviews clinical issues with coding staff, nurses and others to ensure appropriate inpatient technical diagnosis and procedural coding.
- Seeks opportunities to discuss cases with physicians/providers at meetings, rounding and medical staff meetings.
- Maintains a collaborative working relationship with quality, case management and HIM staff.
- Inputs activities from concurrent reviews into CDI software and ensures consistency of data captured.
- Maintains familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission.
Bachelor’s Nursing Preferred
Additional Educational Requirements
Graduate of an accredited school of Registered Nursing
1 Year Coding Experience Preferred
2 Years Clerical Experience In A Healthcare Environment Required
Licenses and Certifications:
Current NJ RN License Required
Additional Certification/Licensure Requirements
CCDS must be obtained within two years of hire. Certified Coding Specialist designation (CCS, CSS, CCS-P from AHIMA) preferred.
Required Knowledge and Skills:
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Excellent written and verbal communication skills, excellent critical thinking skills. Excellent interpersonal skills to build effective partnering relationships with physicians, nurses, and hospital staff. Ability to work independently in a time oriented environment. Working knowledge of inpatient admission criteria. Working knowledge of Medicare reimbursement system and coding structures desired. An understanding of coding classifications systems such as, but not limited to, ICD-9/10CM, APR-DRG preferred. Knowledge of care delivery documentation systems and related medical record documentation. Prior documentation specialist experience preferred.
CentraState Healthcare System, a partner of Atlantic Health System, is a fully accredited, not-for-profit, community-based health system that provides comprehensive health services in the central New Jersey region. In addition to offering a full range of leading-edge diagnostic and treatment options, CentraState serves as a valuable health partner focused on the latest ways to prevent disease, promote healthy behaviors, and help people of all ages live life well. Based in Freehold, CentraState is comprised of a 284-bed acute-care hospital, a vibrant health and wellness campus, three award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions offering primary care and specialty physician practices, along with access to outpatient services, such as lab and physical therapy. The system also offers a family medicine residency and geriatric fellowship training program in affiliation with Rutgers Robert Wood Johnson Medical School. Among its many honors and accreditations, CentraState is one of less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence four times and was designated a Great Place to Work-Certified™ Company by Great Place to Work® for the second consecutive year.
When you bring your talent to CentraState, you are joining a trailblazing healthcare facility, committed to providing high-quality, patient-focused care. Join us in making incredible strides in health care, and making a difference in our community. We believe in enriching the lives of our employees through work/life balance initiatives, tuition assistance, career advancement opportunities and much more.
Find out why our employees love their jobs and being part of the CentraState family!
What We Offer:
- Highly competitive compensation
- Excellent benefits package and rewards program
- 403(b) retirement plan with company match
- 401(a) retirement plan with employer contribution
- Life Insurance
- Tuition Reimbursement Program
- Profit Sharing Program
- Growth Opportunity and Workforce Development Initiatives
- Continuing Education / Onsite Training
- A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
- Concierge Services with Work & Family Benefits
- Magnet recognized healthcare facility
At CentraState Healthcare System, we welcome and promote the diversity of our employee family! Each unique person contributes to the overall success of this organization. Our inclusive culture fosters an environment of professionalism and respect for personal differences.
CentraState Healthcare System, is an equal employment opportunity employer and federal contractor or subcontractor and, therefore, abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, gender identity or expression, sexual or affectional orientation, national origin or nationality, citizenship status, disability, age, genetics, protected veteran status, ancestry, marital status.