The Clinical Documentation Improvement Specialist (CDIS) is responsible for utilizing clinical expertise to evaluate concurrent documentation and appropriate levels of service delivered to patients at Englewood Hospital & Medical Center. Through interaction with physicians, nurses, Health Information Management DRG Specialists/coders, the Clinical Documentation Improvement Specialist (CDIS) will be responsible for facilitating modifications to the overall quality and completeness of medical record documentation. This will support the appropriate clinical picture, the level of severity of the patient and will provide accurate and complete information. The information obtained will be utilized to maximize appropriate reimbursement and in the profiling and outcomes reporting of both the Hospital and the physician.
Excellent documentation, communication and computer skills
Demonstrated ability to function as a team player and work independently
Knowledge of DRG/CMS documentation requirements.
Basic knowledge of ICD-10-CM and Coding guidelines.
Knowledge of DRG grouping requirements.
Previous experience in quality improvement/ documentation improvement activities.
Previous experience working with Medical Staff, other clinicians and HIM staff in a cooperative manner to improve processes.
Previous experience with EPIC EMR preferred.
Bachelor of Science in Nursing required; CCS preferred.
Licensure as an RN in New Jersey
Department: Health Information Management
Location: Englewood, NJ
Status: Full Time
Hours: 40 per week
Englewood Health is one of New Jersey's leading hospitals and healthcare networks. Composed of Englewood Hospital, the Englewood Health Physician Network, and the Englewood Health Foundation, the health system delivers nationally recognized care in a community setting to residents of northern New Jersey and beyond. The hospital, founded in 1890, consistently earns high marks for clinical excellence and patient safety. It is among the top 10% of hospitals in the nation to earn the 2019 Healthgrades Patient Safety Excellence Award. The hospital is also nationally recognized for nursing excellence, earning a fourth consecutive designation by the Magnet Recognition Program® in 2016. Areas of clinical excellence include cardiac surgery and cardiac care, cancer care, orthopedic surgery, spine surgery, vascular surgery, and women's health, as well as bloodless medicine and surgery. Englewood Health is continually expanding services and enhancing access through the Englewood Health Physician Network, a coordinated network of office-based and hospital-based providers at more than 100 locations in six counties in New Jersey and New York. Through the main acute-care facility, physician network, hospital outpatient departments offering imaging services in local communities, and a variety of community health and wellness programs, Englewood Health delivers a healthcare experience that puts patients at the center.
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