004189
PRIMARY FUNCTION :
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 and works primarily in an approved remote home work environment.
ESSENTIAL FUNCTIONS:

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson .
• Accurately reviews medical records concurrently 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, intensity of service, and risk of mortality 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 (attending's, 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.
• Competent in utilizing all computer applications, ie; Epic EHR, 3M DRG, MS Office.
• M aintains productivity expectations. Accurately records activity in CDI software tracking tool.

Qualifications

• EDUCATIONAL/TRAINING REQUIREMENTS :
• Bachelor of Science in Nursing
• Bachelor of Science in Health Information Management or related field.
• Certification, Associate or Bachelor in other healthcare related field with experience noted below.
• CERTIFICATES, LICENSES, AND REGISTRATION:
• CCDS, CDIP certification preferred

• RN/BSN preferred
• RHIA, or RHIT with CCS, MD or DO will be considered
• 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.

EXPERIENCE REQUIREMENTS :

• Working knowledge of Medicare reimbursement system and coding structures preferred.
• 5 years of Critical Care/Emergency medicine or 5 years of Medical Surgical Experience preferred
• 2-3 years Clinical Documentation Improvement experience or 5 years of Coding experience preferred.
• MD/DO with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered.

Closing Statement
Jefferson includes Thomas Jefferson University and Jefferson Health, a dynamic university and health system with broad reach across the Delaware Valley. Jefferson is the second largest employer in Philadelphia and the largest health system in Philadelphia based on total licensed beds.
Through the merger of Thomas Jefferson University and Philadelphia University in 2017, our University includes ten colleges and four schools. We are an NCAA Division II university and an R2 national doctoral university offering undergraduate and graduate-level programs that provide students with a forward-thinking education in architecture, business, design, engineering, fashion and textiles, health, medicine and social science.
Jefferson Health, the clinical arm of Thomas Jefferson University, has grown from a three-hospital academic health center in 2015, to an 18-hospital health system through mergers and combinations that include hospitals at Abington Health, Aria Health, Kennedy Health, Magee Rehabilitation and Einstein Healthcare Network. We have over 50 outpatient and urgent care centers; ten Magnet®-designated hospitals (recognized by the ANCC for nursing excellence); the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in the country and one of only two in the region); and one of the largest faculty-based telehealth networks in the country. In 2021, Jefferson Health became the sole owner of HealthPartners Plan, a not-for-profit health maintenance organization in Southeastern Pennsylvania. We are the first health system regionally to create an aligned payer-provider partnership.
Jefferson's mission, vision and values create an organization that attracts the best and the brightest students, faculty, staff, and healthcare professionals, as well as the most visionary leaders to drive exceptional results.

• OUR MISSION: We improve lives.
• OUR VISION: Reimagining health, education and discovery to create unparalleled value
• OUR VALUES: Put People First, Be Bold & Think Differently and Do the Right Thing

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.