Clinical Document Specialist-Clinical Documentation Mgmt (Full Time, Days) *RN Required*
Company: Saint Barnabas Medical Center
Posted on: October 14, 2021
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
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
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
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.
- Graduate from an accredited school of nursing.
- Must read, write and speak English.
- Prior experience in clinical documentation review preferred as
well as an understanding of ICD-9-CM coding requirements.
- Passing grade on JATA clinical test.
- Minimum 2 years acute hospital experience as a clinical
- Licensure/Certification/Registration: at least one of the
following required: RN/ BSN; CDS certification desired.
- Supervisory experience preferred (in any discipline)
- Successful completion of site personnel general
- Successful completion of department specific orientation.
OUR MISSION, VISION & VALUES:
Employees of Saint Barnabas Medical Center are committed to
exemplifying the Standards of - Exceptional Communication,
Compassionate Care, Outstanding Teamwork, Professional Integrity
and Ownership & Accountability - creating an environment of
Healthcare Excellence and Superior
Service (CCHESS) for all that enter our facility.
If you share the commitment, dedication and drive meet the
CCHESS challenge, we welcome your application.
Since 1865, Saint Barnabas Medical Center (SBMC), located at 94
Old Short Hills Road in Livingston, is New Jersey s oldest
nonprofit, nonsectarian hospital. The 597-bed institution is one of
the largest health care providers in the state, treating more than
35,500 inpatients and over 84,000 Emergency Department patients
each year. The Medical Center and the Saint Barnabas Ambulatory
Care Center provide treatment and services for more than 300,000
outpatient visits annually.
The Medical Staff is comprised of more than 1,600 physicians in
100 medical and surgical specialties and there are over 3,400
employees. As a teaching institution, we have nine residency
programs and one fellowship in Mammography and a shared Nephrology
fellowship with Newark Beth Israel. There are a total of 154
residents and fellows.
Among Saint Barnabas nationally recognized facilities are The
Burn Center, the only certified burn treatment facility in the
state; the Barnabas Health Care System Renal and Pancreas
Transplant Division, one of the most active transplant programs in
the country; The Saint Barnabas Heart Centers, a world-class
cardiac surgery program in affiliation with Newark Beth Israel
Medical Center; The Neurology and Neurosurgery Program which is the
only program in New Jersey to be ranked by US News and World Report
as a Top Hospital for Neurology and Neurosurgery. It is led by an
unprecedented team of experts dedicated to diagnosing and treating
disorders of the brain and nervous system; the Regional Perinatal
Center, providing care for high-risk and critically ill infants in
New Jersey s leading Level III, a 56-bed Neonatal Intensive Care
Unit; comprehensive Pediatric Services including a dedicated
intensive care unit; The Bariatric Surgery Center of Excellence,
designated by the American Society of Bariatric Surgery; a
nationally accredited Chest Pain Center, The Center for Sleep
Disorders; The Comprehensive Stroke Center at Saint Barnabas;
extensive services in robotic and minimally-invasive surgery, The
Institute for Reproductive Medicine and Science at Saint Barnabas,
the widely recognized assisted reproductive technology program; and
comprehensive cancer programs and services that includes one of the
largest Radiation Oncology programs in northern New Jersey and a
highly-specialized Gastrointestinal Cancer Center of
SBMC is an equal opportunity employer.
Keywords: Saint Barnabas Medical Center, Newark , Clinical Document Specialist-Clinical Documentation Mgmt (Full Time, Days) *RN Required*, Other , Newark, New Jersey
Didn't find what you're looking for? Search again!