Clinical Documentation Improvement Specialist (Full Time) Day Shift, Jefferson Health Northeast

Education: Associate or Bachelor of Science in Nursing. Associate or Bachelor of Science in Health Information Management or related field
Experience:

• Three to five years experience in ICD-10-CM coding and DRG assignment, and/or
• RN with 5 years acute care Med/Surg, Critical Care or Emergency Department experience, or
• RN with 5 years Care Management experience
• 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.

Licensure/Certification/Registration Requirements:

• RN, RHIA or RHIT with CCS, MD or DO, CCDS
• 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.

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.

• Concurrently reviews inpatient medical records for proper documentation 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 classifications.

• Identify principal diagnosis and working DRG for each case reviewed. Update the target DRG upon subsequent reviews.
• Provide real-time intervention/education to physician regarding documentation needed for correct coding and regulatory compliance and/or documentation deficiencies that are noted through the concurrent review process.
• Identify consistently absent data in order to identify barriers to achieving highest DRG assignment and accurate severity of illness scores.
• Prepare well written and verbal queries to communicate with physician regarding missing, incomplete or clarifying information needed in the medical record.
• Supports the importance of accurate, complete, timely and consistent documentation practices for the production of quality healthcare data.
• Track and trend issues identified during concurrent reviews.
• Review medical record for other identified regulatory requirements as applicable.

Covid Vaccination is a requirement for employment at Jefferson for employees working at Jefferson’s clinical entities or at the University. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date if you are offered employment, unless you request and receive an approved medical or religious exemption from Jefferson.