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Coloradoacc

Clinical Documentation Spec

Coloradoacc, Convent Station, New Jersey, us, 07961

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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:

Bachelor of Science Nursing degree preferred

Associates Degree in Nursing minimum required

5 years of Med/Surg acute care clinical experience required, experience in ICU strongly 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.

About Us At Atlantic Health System, our promise to our communities is; Anyone who enters one of our facilities, will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 20,000 team members. Headquartered in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation.

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We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.

We have received awards and recognition for the services we have provided to our patients, team members and communities.

100 Best Companies to Work For (r) and FORTUNE(r) magazine for 15 years

Best Places to Work in Healthcare - Modern Healthcare

150 Top Places to work in Healthcare - Becker's Healthcare

100 Accountable Care Organizations to Know - Becker's Hospital Review

Best Employers for Workers over 50 - AARP

Gold-Level "Well Workplace": Wellness Council of America (WELCOA)

One of the 100 Best Workplaces for "Millennials" Great Place to Work(r) and FORTUNE(r) magazine

One of the 20 Best Workplaces in Health Care: Great Place to Work(r) and FORTUNE(r) magazine

Official Health Care Partner of the New York Jets

NJ Sustainable Business

Benefits 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:

Team Member Benefits

Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)

Life & AD&D Insurance.

Short-Term and Long-Term Disability (with options to supplement)

403(b) Retirement Plan: Employer match, additional non-elective contribution

PTO & Paid Sick Leave

Tuition Assistance, Advancement & Academic Advising

Parental, Adoption, Surrogacy Leave

Backup and On-Site Childcare

Well-Being Rewards

Employee Assistance Program (EAP)

Fertility Benefits, Healthy Pregnancy Program

Flexible Spending & Commuter Accounts

Pet, Home & Auto, Identity Theft and Legal Insurance

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Pay Transparency Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.

EEO STATEMENT Atlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.

Job Info

Minimum Salary (Hourly Rate): 48.000000

Maximum Salary (Hourly Rate): 84.500000

Assignment Category: Full-time

Hours per Week: 37.5

Primary Shift: Day

Salary Admin Plan: ALH

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