NJ Employer Clinical Document Specialist in Toms River, New Jersey

CLINICAL DOCUMENT SPECIALIST Job Number: REQ34941-POS61935Category: Professional / ManagementLocation: Toms River, NJ Community Medical Center, an affiliate of RWJBarnabas Health System, is a 592-bed, fully accredited acute care hospital offering area residents world-class medical treatment with the comforts of hometown care. Opened in 1961, CMC has evolved into the state s largest non-teaching hospital and Ocean County s largest and most active health care facility caring for over 24,200 inpatients, 142,500 outpatients and 81,400 emergency department patients each year. Community Medical Center is dedicated to advancing the quality of life and health of our community while delivering compassionate care for our patients. Our core values include: Compassion, Quality, Accountability, Integrity, Diversity and Teamwork. The Clinical Documentation Specialist (CDS) responsibilities include assisting in clarifying documentation regarding the patient s diagnoses and/or procedures, co-morbid conditions, complications, and other reportable data elements. Clarifications will be completed by utilizing computer software to generate the clarification. A clarification is defined as a question posed to a physician to obtain additional documentation to improve the specificity and completeness of the chart documentation elements used to assign diagnosis and procedure codes or other reportable data elements within the health record. A physician clarification is recommended when an inpatient medical record has incomplete, inconsistent, unclear, ambiguous or conflicting documentation. Clarifications should be written in the following situations: Clinical indicators of a diagnosis are present, but there is no documentation of the condition Will offer multiple choices within the clarification Clinical indicators or evidence for a higher degree of specificity or severity (SOI; ROM) A cause-and-effect relationship between two conditions not documented The underlying cause when admitted with only symptoms A treatment is documented without a diagnosis documented Present on admission (POA) indicator status is not well defined Acuity of conditions (acute, chronic, acute on chronic) Conflicting documentation between the attending physician and other healthcare providers The physician clarification will: Not lead the physician to a particular, desired response or introduce any new information Be clearly and concisely written - contain precise language as directed by J A Thomas - The Guide. Present facts from the medical record and identify why the clarification is needed Capture Severity of Illness (SOI) and Risk of Mortality (ROM) Present multiple options Utilize a 360 degree approach including: clinical indicators; treatment; and risk factors All questions posed to the provider will be based on clinical indicators, risk factors, and treatment/management to ensure compliance and consistency of policy and process. All physician clarification responses must be documented in a primary source of documentation. Sources of documentation are: the face sheet, H and P, consultation notes, progress notes, and discharge summary. At Community Medical Center, you will find a progressive health care organization offering a comprehensive array of wellness and medical services including world-class cancer, diabetes, emergency, and cardiac care. We are one of the area s most trusted providers of maternal and child health services, offering superior obstetric services, a Level 2 special care nursery, and a dedicated pediatric unit. We maintain award-winning centers of excellence for women, children and seniors. The centers offer support groups in addition to fitness and wellness programs, to enhance the overall health of every member of our community. EOE.