Clinical Information System Specialist jobs in New Brunswick, NJ

Clinical Documentation Integrity (CDI) Specialist ED
Clinical Document-Coding Mgmt

The Clinical Documentation Integrity (CDI) Specialist ED will:

• Use advanced clinical knowledge and understanding medical necessity guidelines, reviews ED physician/health provider documentation to ensure clinical information meets criteria for certifying an inpatient admission, observation encounter, or other outpatient status designation.
• Initiate collaboration with ED physician/health providers when clinical documentation requires improved specificity.
• Monitor and evaluate medical necessity for ancillary testing while a patient is in an observation status, and if that testing can be performed as an outpatient.
• Comprehensive knowledge regarding payer contractual requirements governing inpatient and observation designation.
• Utilize Case Management software to capture essential admission clinical review documentation.
• Assign the initial provisional DRG assignment for inpatient admissions.
• Ensure comorbid conditions are clearly documented to support optimal DRG assignment.
• Partner with Physician Advisors for admission reviews related to patients being discharged less than two midnights.

Requirements:

• Medical School Graduate required, with preferred CDI experience.
• CDI certification preferred, but will train. CCDS (ACDIS) OR CDIP (AHIMA) is required but will train. Certs must be achieved within one year of hire.
• Requires excellent interpersonal, writing, and communication skills.

Grade 129