The Clinical Documentation Specialist communicates with physicians, case managers, coders, and other health team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients; identifies opportunities for documentation improvement to ensure accuracy and completeness documentation used for measuring and reporting physician and hospital outcomes; provides education to all physicians and other clinicians related to compliant documentation responsibilities and coding and reimbursement issues; acts as consultant to coders when additional information or documentation is needed to assign the correct DRG.
Ability to read and communicate in the English language
BSN, RN and/or RHIA, RHIT, CCS required
A minimum of five years of coding experience is preferred
Working knowledge of Medicare reimbursement system and coding structures required
Motivated, organized with excellent interpersonal communication skills, analytical skills, strong facilitation and presentation skills
PC proficiency with Microsoft Word, Excel and 3M Encoder
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 7,800 students from nearly 40 states and 40 countries with 21 st century professional education. We have 30,000 employees.
Jefferson Health , with 14 hospitals (three are Magnet-designated by the ANCC for nursing excellence) and 50+ 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 . This year, U.S. News & World Report has ranked Thomas Jefferson University Hospital as the 16 th best hospital in the nation, and among the nation’s best in 11 specialties. Jefferson Health also includes the NCI-designated Sidney Kimmel Cancer Center; it is one of only 69 such centers in the nation.
Thomas Jefferson University, nationally recognized for advancing groundbreaking developments in healthcare education and research, recently combined with Philadelphia University, internationally known for architecture, design, engineering, textiles and more. Jefferson (Philadelphia University + Thomas Jefferson University) has nine colleges and three schools dedicated to interprofessional 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, the Jefferson Enterprise 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.
VISIT Jefferson Health
VISIT Jefferson (Philadelphia University + Thomas Jefferson University