Job Summary:
The Clinical Document Specialist is responsible for ensuring accurate and compliant physician documentation in the electronic medical record. When Physician Documentation is accurate and compliant, it increases reimbursement, improves quality outcomes and allows for disease tracking/trending.
Qualifications:
Required:Preferred:
Certifications and Licenses Required:
Scheduling Requirements:
Essential Functions:
The Clinical Documentation Specialist (CDS) responsibilities include assisting in clarifying documentation regarding the patient s diagnoses and/or procedures, co-morbid conditions, complications, and other reportable data elements. Clarifications will be completed by utilizing computer software to generate the clarification. A clarification is defined as a question posed to a physician to obtain additional documentation to improve the specificity and completeness of the chart documentation elements used to assign diagnosis and procedure codes or other reportable data elements within the health record.
A physician clarification is recommended when an inpatient medical record has incomplete, inconsistent, unclear, ambiguous or conflicting documentation.
Clarifications should be written in the following situations:
Clinical indicators of a diagnosis are present, but there is no documentation of the condition
Will offer multiple choices within the clarification
Clinical indicators or evidence for a higher degree of specificity or severity (SOI; ROM)
A cause-and-effect relationship between two conditions not documented
The underlying cause when admitted with only symptoms
A treatment is documented without a diagnosis documented
Present on admission (POA) indicator status is not well-defined
Acuity of conditions (acute, chronic, acute on chronic)
Conflicting documentation between the attending physician and other healthcare providers
Other Duties:
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Benefits and Perks:
At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.
Choosing RWJBarnabas Health!
RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.
RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.
Equal Opportunity Employer
...motivated and experienced Crew Foreman to lead our Horizontal Directional Drilling (HDD) crew in Indianapolis, IN. In this hands-on role, you'... .... ~ Work for a forward-thinking and innovative company. ~ Ecological footprint - We are rehabbing the world's infrastructure...
We are seeking a full-time AM Pastry Assistant for our expanding French restaurant in Santa Monica. In this role, you will have the opportunity to learn while creating modern interpretations of French classics, including St. Honor, seasonal fruit tarts, laminated breads...
...traceability and purity of biological substances and products. Job Description Job Summary: Eurofins BPT is seeking a Document Control Specialist role to join their team full-time in Columbia, MO. Maintain document control records and accurately enter new...
...dependable service and honest work. We serve both residential and commercial clients across SWFL and were looking for a reliable receptionist to handle daily office tasks and keep operations running smoothly. Job Summary: This is an office-based role with no...
...Massachusetts, Nexthink has 9 offices worldwide. #LI-Hybrid Job Description The SDM manages the delivery of scoped Managed Services to Nexthink customers. They play a pivotal role in supporting the customer to realise value from the Nexthink platform, and as...