Clinical Documentation Improvement Specialist

About Us

Cooper University Health Care is an integrated healthcare delivery system serving residents and visitors throughout Cape May County. The system includes Cooper University Hospital Cape Regional; three urgent care facilities; nearly 30 primary care and specialty care offices in multiple locations throughout Cape May County; The Cancer Center at Cooper University Hospital Cape Regional; the Claire C. Brodesser Surgery Center; AMI at Cooper, Miracles Fitness and numerous freestanding outpatient facilities providing wound care, lab, and physical therapy services. We have a commitment to our employees by providing competitive rates and compensation programs. Cooper offers full and part time employees a comprehensive employee benefits program, including health, dental, vision, life, disability, retirement, on-site Early Education Center (employee discount), attractive working conditions, and the chance to build and explore a career opportunity by offering professional development.

Short Description

• Concurrently review inpatient medical records for clear consistent, concise, legible and accurate documentation to reflect the patient’s severity of illness and intensity of services.
• Generate and utilize queries to clarify physician documentation whenever there is conflicting, ambiguous or incomplete information in the medical record regarding any significant reportable condition or procedure.
• Complete analysis of clinical information to identify gaps in clinical documentation. To “bridge the gap” utilize the physician advisor for clarification of clinical presentation.
• Collaboratively work with HIM Leadership, Coders, Coding Quality Educators/Reviewers and peers to improve accuracy of final DRG. 
• Collaborate and provide educational support to physicians, nurses and ancillary staff to facilitate modifications of clinical documentation processes that promote documentation improvement.
• Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients.
• Provide clinical review of cases denied for medical necessity by auditing agencies. Using knowledge of medical necessity criteria assist physician advisor in collecting pertinent information to support an appeal.

Education Requirements

Bachelor of Science in Nursing preferred; however, candidates with any bachelor’s degree will be considered if they have CDI experience.

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