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The Clinical Document Improvement Specialist - (CDS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients.
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Current license from the Board of Nurse Examiners of the State of Texas to practice as a registered nurse; National certification (e.g. CDS, CCRN, RNC, CEN, CNOR, OCN, ANCC, CAN, CPAN, CFRN, etc.
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CDS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients.
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Communicates the transfer of appropriate concurrent information to the inpatient Case Managers and the Clinical Documentation Specialists (CDS), assigned to the unit. 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.
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An active NJ state medical license, DEA and CDS are required to be secured by the date of employment. This is a full time role with call responsibility across the inpatient and outpatient settings, focusing on complex pulmonary disorders.
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The Clinical Documentation Specialist (CDS) provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation of acute care services.
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Reviews Inpatient health record documentation, as part of the coding process, to assess the presence of clinical evidence/indicators to support diagnosis code and MS-DRG, APR DRG assignments to potentially decrease denials.
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Works with Clinical Documentation Specialists (CDS) and physicians to identify and address documentation improvement needs that support accurate code, Risk of Mortality (ROM), Severity of Illness (SOI), and DRG assignment.
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Charts via written, dictation, or electronic means: admission notes, history and physical examinations, consultations, daily patient encounter notes, urgent evaluation notes, minor procedure notes, and brief post-operative notes as it pertains to patients in the inpatient or outpatient setting; present this information to the supervising physician.
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The successful candidate will join the growing Department of Obstetrics, Gynecology and Women's Health at Rutgers New Jersey Medical School located in Newark NJ. The physician will provide ambulatory and inpatient care on the Bergen New Bridge campus in Paramus, NJ. Provides direct clinical care to patients in general adult population.
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This positon trains and audits Inpatient and Outpatient Clinical Documentation Specialists (CDS) across all HCS entities that are owned or managed that have opted into shared services. Provides ongoing documentation and coding education to CDI Physician Advisers and CDS staff.
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Demonstrates knowledge of current, compliant coder query practices when consulting with physicians, Clinical Documentation Specialists (CDS) or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous documentation.
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CHMG currently offers pulmonology services across our hospitals located in Pennington, NJ and Trenton, NJ, along with outpatient offices located in Pennington, NJ, Hamilton, NJ, and Newtown, PA. As part of the Capital Health System, providers have access to a broad range of in-house testing, ICU support, and access to a robust pulmonary lung nodule clinic and interventional pulmonology program, now equipped with the Ion robotic bronchoscopy system.
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CHMG requires that all providers hold dual licensing in New Jersey and Pennsylvania, along with active board certification or board eligibility in pulmonary disease and critical care medicine. The physician will cover the Hopewell Medical Center and Regional Medical Center during consult weeks and be assigned to a mix of outpatient offices.
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ResponsibilitiesIs an intermediate level position for experienced CDS.QualificationsEducation:Required: Graduate of an accredited school of nursing, AHIMA accredited school, United States, or international school of medicine Experience:Required: 2 to 5 years of CDS experience and 2 years recent acute care experience in a clinical or inpatient coding setting; or MBBS and USMLE in lieu of experience.
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