A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
About Us At Cooper University Health Care , our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees to provide competitive rates and compensation programs. Cooper offers full and part-time employees a comprehensive benefits program, including health, dental, vision, life, disability, and retirement. We also provide attractive working conditions and opportunities for career growth through professional development. Discover why Cooper University Health Care is the employer of choice in South Jersey. Short Description Responsible for ensuring the overall quality and completeness of medical record documentation. Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis. Professional team player, able to communicate well with others on all levels. Regular significant contacts with other personnel throughout and outside the hospital. Contacts may be in person, by telephone or-through correspondence. Flexible with a working knowledge of all areas of adult medicine. Occasional lifting/carrying up to fifteen pounds, as well as reaching, stretching, stooping, bending, kneeling, crouching, standing, walking and pushing/pulling to move and file medical records alone or in carts. Ability to sit for long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer and other office equipment. Adequate to perform essential functions of the job with the type of judgments and potential consequences outlined above. Experience Required Knowledge of medical record documentation requirements coding guidelines. Related Computer knowledge of Epic a plus. Education Requirements RN preferred or CCS, CPC or RHIT preferred. License/Certification Requirements NJ-RN License (Registered Nurse) preferred CCS, CPE or RHIT preferred.
Special Requirements Essential mental abilities:
good critical thinking skills, able to assess, evaluate and teach. Requires excellent observation skills, analytical thinking, problem solving, computer skills, good verbal and written communication. Salary Min ($) USD $41.00 Salary Max ($) USD $70.00
