Documentation Specialist jobs in Bergenfield, NJ
Recently Added Documentation Specialist jobs
Clinical Documentation Specialist
- Hackensack Meridian Health
-
Hackensack, NJ
FULL_TIME
-
Overview:Our team members are the heart of what makes us better.
At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.
Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.Responsibilities:
The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation for assigned hospital/s of Hackensack Meridian Health (HMH). 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 the patient care team on documentation guidelines, on an on-going basis. 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. 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.A day in the life of a Clinical Documentation Specialist at Hackensack Meridian Health includes:
- Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
- Performs admission reviews for specific patient populations using clinical documentation guidelines.
- Assists in the medical screening process by documenting appropriateness of patient admission, working DRG & LOS information on worksheet and computer system as appropriate.
- Extensively reviews all physician and clinical documentation, lab results, diagnostic information and treatment plans and captures appropriate information on 3M 360 worksheet.
- Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption.
- Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified.
- Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities.
- Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses.
- Reviews medical record every 24-48 hours as appropriate.
- Updates 3M 360 worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate.
- Updates 3M 360 worksheet to reflect any changes in DRG and/or APR assignment.
- Communicates with physicians to ensure that requests for documentation have been noted.
- Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures.
- Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in the patient's chart.
- As appropriate, documents and analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to leaders of Health Information.
- Follows established CDMP process for follow-up reviews and physician communication.
- Reviews clinical issues with coding staff to assign working DRG using software.
- Collaborates with coding staff as needed to determine appropriate DRG and required documentation.
- Utilizes coding staff knowledge of Coding Clinics that impact CDMP.
- Provides clinical expertise and references to the coding staff.
- Follows established guidelines for reconciling final coded DRG with the CDMP DRG assigned at the time of discharge.
- 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.
- Attends and participates in weekly educational conferences.
- Participates in concurrent performance improvement activities and on-going MR review activities.
- Reviews 3M 360 tracking data in conjunction with established benchmarks.
- Provides overview of CDMP to new staff, allied health professionals and physicians.
- Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Coding Compliance Manager, Department Director and Emergency Trauma Dept.
- Screens ED inpatient admissions and observations determining the necessity and appropriateness of hospitalizations using facility criteria.
- Recommends admission or observation disposition to the ED physician in accordance to the screening.
- Collaborates with admitting physicians to place patients in appropriate status.
- CDS must attend/participate in Multidisciplinary Rounds (MDR) of their designated/assigned unit.
- Communicates with physicians when screening criteria is not met for inpatient and requests additional documentation if appropriate.
- Reviews concurrent and post coding pre-billing medical records for completeness and accuracy for severity of illness (SOI) using the Compliant Documentation Management Program (CDMP) documentation strategies.
- Initiates 3M 360 severity worksheet for inpatients.
- Requests documentation clarification as appropriate for SOI.
- 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.
- Documents assessments in the medical record.
- 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.
- 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.
- Maintains liaison with the inpatient case manager and communicates necessary follow up.
- Maintains liaison with inpatient CDS and provides report summary.
- Performs other duties and/or projects as assigned.
- Adheres to HMH Organizational competencies and standards of behavior.
Education, Knowledge, Skills and Abilities Required:- Graduation from medical school.
- Minimum of 5 or more years of experience reviewing and screening inpatient admissions and observations or equivalent experience.
- Experience assessing patients and improving the quality and ensuring compliance of medical records documentation or equivalent experience.
- Ability to interact well with physicians and other members of allied health care team, including HIM coders.
- Must be computer literate, have working knowledge and familiarity of Google and/or Microsoft based software programs/applications.
- Must possess excellent communication, organizational, analytical, writing and interpersonal skills.
- Dependable, self-directed and pleasant.
- Critical thinking, problem solving and deductive reasoning skills.
- Recent hospital experience.
- Knowledge of Pathophysiology and Disease Process.
- Knowledge of Medicare Part A.
- Familiar with Medicare Part B.
- Knowledge of the regulatory environment.
- Understand and support CDMP® documentation strategies.
- Knowledge of POA/HAC and core measures.
- Knowledge of Observation and Inpatient medical necessity.
- Knowledge of regulatory requirements for appropriateness of admissions.
Education, Knowledge, Skills and Abilities Preferred:- ICU, CCU and/or strong Medical/Surgical experience.
Licenses and Certifications Required:- Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility.
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today! - 13 Days Ago
Clinical Documentation Specialist
- HACKENSACK UNIVERSITY MED CNTR
-
Hackensack, NJ
FULL_TIME
- Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in c...
- 13 Days Ago
Business Operations Specialist
- Technology Support Specialist
-
Ridgefield, NJ
FULL_TIME
- Top 3 Skills:Good CommunicationAbility to complete tasks on timeStrong analytics with attention to detail Summary:The main function of a business operations specialist is to maintain vendor relationsh...
- Just Posted
Supply Chain Analyst
- Technology Support Specialist
-
Ridgefield, NJ
CONTRACTOR
- Top 3 Must Have Skills:1) Highly organized and follows instructions closely2) Very detail oriented3) Must follow up on multiple tasks4) Intermediate to Advance Excel skills. Extension every 6 months i...
- 18 Days Ago
Roofing Sales Trainee
- Home Specialist MV LLC
-
Hackensack, NJ
FULL_TIME
- Roofing Sales Trainee Need a change in your career? **Willing to train the right candidate** We're looking for a motivated individual to train as a Roofing Sales Manager and lead our sales team to suc...
- 18 Days Ago
Sales Administration
- Technology Support Specialist
-
Ridgefield, NJ
FULL_TIME
- op 3 Skill Sets: Sales Administration & Operations, Strong Communications, Very Advanced ExcelEducation Requirement: BachelorsYears of experience: 3Team?s Work Schedule: Hybrid, 4 days onsite-85 Chall...
- Just Posted
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0 Documentation Specialist jobs found in Bergenfield, NJ area
Technical Document Specialist
- NEW YORK EHEALTH COLLABORATIVE INC
-
New York, NY
- Job Details Job Location Albany or NYC Office - Albany or New York, NY Position Type Full Time Travel Percentage Occasio...
- 4/26/2024 12:00:00 AM
Clinical Documentation Specialist
- Northwell Health
-
Great Neck, NY
- Job Description Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to ...
- 4/26/2024 12:00:00 AM
Clinical Documentation Specialist (Hybrid position)
- NYU Langone Health
-
New York, NY
- NYU Langone Health is a world-class, patient-centered, integrated academic medical center, known for its excellence in c...
- 4/26/2024 12:00:00 AM
Export Documentation Specialist
- Fornazor International, Inc.
-
Hillsdale, NJ
- Company Description Fornazor International, Inc. It is a perennial top 100 US export company providing feed ingredients ...
- 4/25/2024 12:00:00 AM
Documentation Specialist
- Tower Fund Capital
-
New York, NY
- Job Description Job Description Document coordinator for merchant cash advance company
- 4/23/2024 12:00:00 AM
Loan Documentation Specialist
- Valley National Bancorp
-
Wayne, NJ
- The Loan Documentation Specialist will use software and Word templates to prepare commercial loan documents that accurat...
- 4/23/2024 12:00:00 AM
Documentation Specialist
- Richmond University Medical Center
-
Staten Island, NY
- CDS Job Summary: The CDS facilitates accurate documentation for severity of illness (SOI) and quality in the medical rec...
- 4/22/2024 12:00:00 AM
Documentation Specialist I (Manufacturing/Quality)
- Pyramid Consulting, Inc
-
Ridgefield, NJ
- Immediate need for a talented Documentation Specialist I (Manufacturing/Quality). This is a 12+ Months Contract opportun...
- 4/22/2024 12:00:00 AM
About Bergenfield, New Jersey
Bergenfield is a borough in Bergen County, New Jersey, United States. As of the 2010 United States Census, the borough's population was 26,764, reflecting an increase of 517 (+2.0%) from the 26,247 counted in the 2000 Census, which had in turn increased by 1,789 (+7.3%) from the 24,458 counted in the 1990 Census.
Bergenfield was formed on the basis of a referendum held on June 25, 1894, from portions of Englewood Township and Palisades Township.[21][22][23] The borough was formed during the "Boroughitis" phenomenon then sweeping through Bergen County, in which 26 boroughs were formed in the co...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Documentation Specialist jobs
$49,420 to $69,619
Bergenfield, New Jersey area prices
were up 1.5% from a year ago
were up 1.5% from a year ago
What does a Documentation Specialist do?
Documentation Specialist in Chanhassen, MN
File, reproduce, and maintain documentation to support various departments.
May 05, 2023
Documentation Specialist in Coral Springs, FL
Produce a significant portion of complex documentation set that complies with documentation plan requirements.
April 04, 2023
Documentation Specialist in Havelock, NC
Assist the assigned Fleet Support Team (FST) at Technical Manual Management Team (TMMT) Conferences In-Process reviews, verification and Integrated Logistics Support Team Meetings.
May 01, 2023