Clinical Documentation Improvement Specialist

Tracks and trends issues identified during concurrent reviews.

Actively contribute to the continued improvement and success of the department and the hospital.

frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than

part-time (including

per diem

colleagues, adjunct faculty, and Jeff Temps

), have access to medical (including prescription) insurance.

here

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.