Clinical Documentation Specialist, Days, FT 37.50 hrs
RWJ Barnabas Health
September 15, 2018
Belleville, New Jersey
Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program® (CDMP®) documentation strategies Accurate and timely record review Recognize opportunities for documentation improvement Initiates CDMP® severity worksheet for inpatients Formulate clinically credible documentation clarifications
Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety Effective and appropriate communication with physicians Timely follow up on all cases and resolution of those with clinical documentation clarifications Participate in Task Force Meetings Manage multiple priorities Communicates with HIM staff and resolves discrepancies Accurate input of data into CDMP Trak®
Ability to learn/develop the skills necessary to perform CDMP® Organizational, analytical, writing and interpersonal skills Dependable, self-directed and pleasant Critical thinking, problem solving and deductive reasoning skills Knowledge of Pathophysiology and Disease Process Basic Computer skills, familiarity with Windows based software programs Knowledge of regulatory environment Understand and support CDMP® documentation strategies (upon completion of training) Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training) Knowledge of Core Measure and Patient Safety Indicators (upon completion of training) . 5 years of adult acute care experience in Med/Surg, Critical Care, Case Management, Emergency Room, or PACU.
Graduation from a program of nursing, BSN, preferred. Current State Registered Nurse License.
Able to work on weekends.
Internal Number: REQ35549-POS62128
About RWJ Barnabas Health
Welcome to Barnabas Health, New Jersey’s largest integrated health care delivery system. It includes Clara Maass Medical Center in Belleville; Community Medical Center in Toms River; Kimball Medical Center in Lakewood; Monmouth Medical Center in Long Branch; Newark Beth Israel Medical Center in Newark; Barnabas Health Behavioral Health Center in Toms River; and Saint Barnabas Medical Center in Livingston. The System also includes the Barnabas Health Outpatient Centers with the Barnabas Health Ambulatory Care Center in Livingston and the Saint Barnabas Family Imaging and Breast Center in Bedminster; ambulatory care facilities, geriatric centers, a state-wide behavioral health network and comprehensive home care and hospice programs.Barnabas Health's 19,600 employees (second largest private employer in the state) and 4,750 physicians (one-fourth of N.J. practicing physicians), and 450 residents provide treatment and services for more than 225,00...0 inpatients and same day surgery patients, 451,000 Emergency Department patients and over 1.5 million outpatients each year, and deliver more than 17,500 babies annually.Among our nationally recognized services and facilities are New Jersey’s only certified burn treatment facility; world-class cardiac surgery services for adults and pediatrics; the state’s oldest, most experienced center for heart transplants, ranked in top 10 by volume in the nation; New Jersey’s only lung transplant program; two kidney transplant centers which are among the largest in the nation with 35 years of experience; six certified chest pain centers by the American Society of Chest Pain Centers; three Joint Commission-accredited Primary Stroke Centers, one Comprehensive state-accredited Stroke Center, and three state-accredited Primary Stroke Centers.Our renowned services also include the most comprehensive robotic surgery service in the region with cardiothoracic surgery, general surgery, adult and pediatric urology, gynecology, and gynecologic oncology; a highly respected neurology and neurosurgery program; a widely recognized reproductive medicine and science program; nationally recognized geriatric services; comprehensive cancer services, providing patients with state-of-the-art technology and cutting-edge treatment options through participation in clinical research trials; three Valerie Fund Children’s Centers for Cancer and Blood Disorders; renowned women’s and children’s services, including Children's Hospital of New Jersey at Newark Beth Israel Medical Center and The Children’s Hospital at Monmouth Medical Center; and New Jersey’s only neonatal ECMO program for life-support.Throughout Barnabas Health, our dedicated physicians, nurses and health professionals are committed to providing the highest quality of patient care and health education to the community and the region.