This position is fully remote work from home for Jefferson Einstein.
Under the direction of CDI Manager, the Clinical Documentation Specialist reviews medical records to facilitate accurate and complete medical record documentation to reflect clinical treatment, decisions, and diagnoses used for measuring and reporting hospital and physician outcomes. Accurately identifies additional documentation opportunities and places appropriate queries and/or communicates with physicians, coders, and other health team members (i.e., PI, Case managers, Nurse Navigators, etc.) for documentation improvement. Works independently in an approved, remote home environment and effectively troubleshoots system issues in accordance with Department policy and procedures.
Extensive clinical knowledge and understanding of pathophysiology demonstrated by experience working in an acute care hospital setting.
Excellent written and verbal communication skills with the ability to write and speak concisely and professionally when communicating with providers
Self-motivated with strong critical thinking and problem-solving skills
Accurately reviews medical records concurrently/retrospectively for completeness in documentation of diagnostic and procedural information for compliance to CMS, DOH regulatory, and financial requirements. Assures documentation of diagnoses, procedures, co-morbid, and complication conditions are reflected on the medical record to support proper severity of illness (SOI), intensity of service, and risk of mortality (ROM) classifications and designated quality reviews (i.e., Patient Safety Indicator reviews).
Prepare well written and compliant queries to communicate with physicians and other providers regarding missing, incomplete or clarifying information needed in the medical record.
Works closely with coding staff to assure that documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
Interacts and continuously educates physicians (attendings, residents and interns), nurse practitioners and physician assistants. Provides real-time intervention/education when needed to promote correct coding, regulatory compliance, and correction of documentation deficiencies.
Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
Maintains productivity expectations. Accurately records activity in CDI software tracking tool.
OTHER FUNCTIONS AND COMPETENCIES needed in addition to Essential Functions:
Expert working knowledge of HIPAA and all laws relative to accessing Protected Health Information (PHI)
Reviews medical record for other identified regulatory requirements as applicable.
Tracks and trends issues identified during concurrent reviews. Attends department meetings. Actively contributes to the continued improvement and success of the department and the hospital.
Attends continuing education meetings, in-services, and training sessions and audioconferences related to coding and CDI to maintain skills and stay abreast of coding guideline changes and best practice CDI processes.
Demonstrates initiative, judgement and creative ability in performance of job duties.
Identifies problems with processes and suggests possible solutions
Functions in a professional, efficient and positive manner.
Performs other duties and assignments, as necessary.
Bachelor of Science in Nursing with
5 years of Critical Care, Emergency Medicine, or Medical Surgical experience preferred
CERTIFICATES, LICENSES, AND REGISTRATION:
CCDS, CDIP certification preferred
RN/BSN licensed in state of PA
CCDS within 6 months of hire for eligible candidates
Maintenance of appropriate registration/certification. Responsible for tracking Continuing Education credits to maintain professional credentials if applicable.
Working knowledge of Medicare reimbursement system and coding structures preferred.
Conditions of Employment
Covid Vaccination is a requirement for employment at Jefferson for employees working at Jefferson’s clinical entities or at the University. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date if you are offered employment, unless you request and receive an approved medical or religious exemption from Jefferson.
Jefferson Health delivers state of the art healthcare services to patients throughout the Delaware Valley and southern New Jersey. Jefferson (Philadelphia University + Thomas Jefferson University) provides more than 8,400 students from nearly 40 states and 40 countries with 21st century professional education. Combined, we have over 30,000 employees.
Jefferson Health, with 14 hospitals (seven are Magnet designated by the ANCC for nursing excellence) and 40+ outpatient and urgent care locations, offers a broad range of primary and complex, highly specialized care that touches the lives of more than four million patients annually. U.S. News & World Report has ranked Thomas Jefferson University Hospital among the nation’s best in eight specialties. Jefferson Health also includes the NCI designated Sidney Kimmel Cancer Center; it is one of only 70 such centers in the nation.
Thomas Jefferson University has ten colleges and three schools that offer more than 160 undergraduate and graduate programs. Our University is dedicated to inter-professional and transdisciplinary approaches to learning that offer a vibrant and expandable platform for professional education. Through this unique model, we are preparing our students for current and yet to be imagined careers.
As an employer, Jefferson maintains a commitment to provide equal access to employment. Jefferson values diversity and encourages applications from women, members of minority groups, LGBTQ individuals, disabled individuals, and veterans.