HackensackRecruiter Since 2001
the smart solution for Hackensack jobs


Company: Hackensack Meridian Health
Location: Hackensack
Posted on: January 15, 2020

Job Description:


Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department (ETD), to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis. The CDS reviews and screens ED inpatient admissions and observations as specified by the facility\'s Utilization Management/Review Committee for documentation completeness and compliance with patient status. Facilitates accurate documentation for severity of illness and medical necessity. Interacts with physicians, case managers, and nursing staff and provides guidance and recommendations for admission or observation disposition. The CDS assesses patients for present-on-admission (POA) conditions to ensure accurate documentation, regarding hospital acquired conditions (HAC). Communicates the transfer of appropriate concurrent information to the inpatient Case Managers and the Clinical Documentation Specialists (CDS), assigned to the unit.


1. Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record. 2. Performs admission reviews for specific patient populations using clinical documentation guidelines. 3. Assists in medical screening process by documenting appropriateness of patient admission, working DRG & LOS information on worksheet and computer system as appropriate. 4. Extensively reviews all physician and clinical documentation, lab results, diagnostic information and treatment plans and captures appropriate information on CDMP / 3M 360 worksheet. 5. Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption. 6. Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified. 7. Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities. 8. Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses. 9. Reviews medical record every 24-48 hours as appropriate. 10. Updates CDMP / 3M 360 worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate. 11. Updates CDMP / 3M 360 worksheet to reflect any changes in DRG and/or APR assignment. 12. Communicates with physician to ensure that request for documentation has been noted. 13. Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures. 14. Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient\'s chart. 15. As appropriate, documents and analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Director of Health Information. 16. Follows established CDMP process for follow-up reviews and physician communication. 17. Reviews clinical issues with coding staff to assign working DRG using software. 18. Collaborates with coding staff as needed to determine appropriate DRG and required documentation. 19. Utilizes coding staff knowledge of Coding Clinics that impact CDMP . 20. Provides clinical expertise and references to the coding staff. 21. Follows established guidelines for reconciling final coded DRG with the CDMP DRG assigned at the time of discharge. 22. Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance. 23. Attends and participates in weekly educational conferences. 24. Participates in concurrent performance improvement activities and on-going MR review activities. 25. Reviews CDMP / 3M 360 tracking data in conjunction with established benchmarks. 26. Provides overview of CDMP to new staff, allied health professionals and physicians. 27. Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Coding Compliance Manager, Department Director and Emergency Trauma Dept. 28. Screens ED inpatient admissions and observations determining the necessity and appropriateness of hospitalizations using facility criteria. 29. Recommends admission or observation disposition to the ED physician in accordance to the screening. 30. Collaborates with admitting physician to place patient in appropriate status. 31. CDS must attend/participate in Multidisciplinary Rounds (MDR) of their designated/assigned unit. 32. Communicates with physician when screening criteria is not met for inpatient and requests additional documentation if appropriate. 33. Reviews medical record for completeness and accuracy for severity of illness (SOI) using the Compliant Documentation Management Program (CDMP ) documentation strategies. 34. Initiates CDMP / 3M 360 severity worksheet for inpatients. 35. Requests documentation clarification as appropriate for SOI. 36. Assesses all appropriate admissions for POA documentation of: a. Pressure ulcers. b. Vascular-catheter associated infections. c. Indwelling urinary catheter associated infections. d. Surgical Site infection (mediastinitis). e. DVT, Pulmonary embolus. f. Risk for falls. 37. Documents assessments in the medical record. 38. Initiates core measure review as indicated for specific clinical topics: a. AMI. b. Pneumonia. c. Heart Failure d. Stroke e. Severe Sepsis & Septic Shock f. Upon identification of Core Measures, follow and adhere to CDMP Core Measures protocols. g. Upon identification of Patient Safety Indicators (PSIs), follow PSI flowsheet and adhere to CDMP protocols. 39. Provides ongoing education to ED and admitting physicians regarding appropriate documentation and criteria for admission, observation, and level of care to comply with federal and state mandates. Uses Milliman and Medicare and other appropriate resources. 40. Maintains liaison with the inpatient case manager and communicates necessary follow up. 41. Maintains liaison with inpatient CDS and provides report summary. 42 .Performs other related job duties as requested. 43. Adheres to the standards identified in the Medical Center\'s Organizational competencies.


Education, Knowledge, Skills and Abilities Required: 1. Graduation from a program of nursing. 2. Ability to interact well with physicians and other members of allied health care team, including HIM coders. 3. Must be computer literate, have working knowledge and familiarity of Microsoft Word and Excel/Windows based software programs. 4. Must possess excellent communication, organizational, analytical, writing and interpersonal skills. 5. Dependable, self-directed and pleasant. 6. Critical thinking, problem solving and deductive reasoning skills. 7. Recent hospital experience. 8. Knowledge of Pathophysiology and Disease Process. 9. Knowledge of Medicare Part A. 10. Familiar with Medicare Part B. 11. Knowledge of regulatory environment. 12.

Meridian Health is committed to the principles of equal employment opportunity and affirmative action and will not discriminate in the recruitment or employment practices on the basis of race, color, creed, national origin, ancestry, marital status, gender, age, religion, sexual orientation, gender identity/expression, disability, veteran status and any other category protected by federal or state law.

Keywords: Hackensack Meridian Health, Hackensack , CLINICAL DOCUMENTATION SPEC RN, Healthcare , Hackensack, New Jersey

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Other Healthcare Jobs

Full time Optometrist - Great M-F opportunity for Optometrist to provide exams to patients in Nursin
Description: Optometrist OD Currently seeking Optometrists for full-time opportunities with an established company that has recently started to provide Optometrists to care for patients in Nursing homes. This is (more...)
Company: ETS Vision
Location: White Plains
Posted on: 01/26/2020

Travel / Locum Tenen PT Jobs Physical Therapist (West Babylon)
Description: Of all the Healthcare Professional specialties we offer, Physical Therapist are one of the specialties that have the most difference between staffing agencies in job / travel assignment locations and (more...)
Company: HealthCare Traveler Jobs
Location: West Babylon
Posted on: 01/26/2020

Licensed Clinical Psychologist
Description: br br Overview br br Licensed Psychologist br br White Plains, NY br br Join a leading APA-accredited, clinician-led behavioral health company today C.H.E. Behavioral Health Services (more...)
Company: CHE Behavioral Health Services
Location: White Plains
Posted on: 01/26/2020

Registered Nurse - RN - Travel Contract
Description: Travel Nurses - RN - Immediate and Future 13 Week Travel Contracts. br br Specialties: Emergency Department Trauma - ED / ER, Intensive Care Unit - ICU, Labor Delivery - L D, Medical/Surgical - (more...)
Company: Accountable Healthcare Staffing
Location: White Plains
Posted on: 01/26/2020

Orthopedic Surgeon
Description: Surgery-General opening in Hicksville, New York. This and other physician jobs brought to you by DocCafe.com A consulting service in New York is looking for an orthopedic surgeon to provide locum
Company: Barton Associates
Location: Hicksville
Posted on: 01/26/2020

Nursing Per Diem, Radiology/CAT scan
Description: OVERVIEW br br The NSG Per Diem Nurse functions as a caregiver for a specific patient population in order to achieve desired outcomes. This position focuses on expanding knowledge and skills, provides (more...)
Company: Hackensack Meridian Health
Location: Hackensack
Posted on: 01/26/2020

Travel Nurse RN - PACU - Post Anesthetic Care - $1,872 per week
Description: NurseFly Travel Nursing with MedPro Healthcare Staffing is seeking a pacu - post anesthetic care travel nurse for a travel nursing job in Berkeley Heights, New Jersey: - Specialty: PACU - Post Anesthetic (more...)
Company: NurseFly Travel Nursing
Location: Lakewood
Posted on: 01/26/2020

Licensed Practical Nurse
Description: Description br Nport Staffing x2F Kindred, a leader in the professional healthcare industry, has openings for LPN's, License Practical Nurse in the -Westchester County area. We are currently looking (more...)
Company: Kindred
Location: White Plains
Posted on: 01/26/2020

Travel RN-Telemetry
Description: ul br li RNnetwork has an excellent travel nurse opportunity in Hackensack, NJ. This is a Tele ER Hold position, and the covering nurse will provide
Company: RNnetwork
Location: Hackensack
Posted on: 01/26/2020

Physician: Dermatologist Needed in New York - JOB-2602504
Description: An exciting dermatologist opportunity is now available in New York. You will start strong by taking care of the current overflow and then build your practice. You will do biopsies and excisions and they (more...)
Company: CompHealth
Location: White Plains
Posted on: 01/26/2020

Log In or Create An Account

Get the latest New Jersey jobs by following @recnetNJ on Twitter!

Hackensack RSS job feeds