Job Description

Responsible for reviewing patient medical records throughout hospitalization to capture accurate representation of the severity of illness and facilitate proper coding. Validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.


Principal Accountabilities:

• Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
• Creates job aids and queries in support of training initiatives
• Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart
• Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding
• Discusses cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings
• Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured
• Serves as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement efforts
• Performs other relevant duties as assigned

Qualifications

Required:

• Associate's degree in Nursing.
• Bachelor of Science Nursing degree preferred
• Registered licensed nurse (RN) required
• Strong clinical knowledge in respiratory failure, sepsis, CHF, ATN/CKD, and complex pneumonias required
• One-two years experience as CDI Specialists preferred
• 3M Coding and Reimbursement and/or 360 Encompass preferred
• Working knowledge of ICD-10 preferred
• Epic experience preferred
  
  Preferred:
  
• Ability to achieve cognitive, organizational and emotional maturity to deal effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers.
• Possesses interpersonal/communication skills necessary for effective, non-judgmental, and empathetic patient care and customer relations.
• Open to feedback and open to a changing environment, which requires flexibility in scheduling and department assignments.
  
  
  
  #LI-AW1

About Us

Atlantic Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:

About the Team

Atlantic Health System is at the forefront of medicine, setting standards for quality health care powered by a workforce of more than 18,000 team members and 4,800 affiliated physicians dedicated to building healthier communities, the system offers more than 400 sites of care, including eight award-winning medical centers. Specializing in cardiovascular care, cancer care, orthopedics, neuroscience, pediatrics, women's health and rehabilitation medicine. Atlantic Medical Group, comprised of 1,000 physicians and advanced practice providers, represents one of the largest multi-specialty practices in New Jersey and includes finance, legal, marketing, human resources, talent acquisition, ISS and more. Caring for our patients, our team members and the communities we serve is our central mission.

Job Info