CLINICAL DOCUMENTATION SPEC - REMOTE

AtCooper University Health Care, our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees to provide competitive rates and compensation programs.  Cooper offers full and part-time employees a comprehensive benefits program, including health, dental, vision, life, disability, and retirement. We also provide attractive working conditions and opportunities for career growth through professional development.

Discover why Cooper University Health Care is the employer of choice in South Jersey.

Responsible for ensuring the overall quality and completeness of medical record documentation.

     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.

     Supports timely, accurate and complete documentation of clinical information used for

     measuring and reporting physician and hospital outcomes.

     Educates all members of the patient care team on an ongoing basis.

     Professional team player, able to communicate well with others on all levels.

     Regular significant contacts with other personnel throughout and outside the hospital.

     Contacts may be in person, by telephone or-through correspondence.

     Flexible with a working knowledge of all areas of adult medicine.

     Occasional lifting/carrying up to fifteen pounds, as well as reaching, stretching, stooping,

     bending, kneeling, crouching, standing, walking and pushing/pulling to move and file

     medical records alone or in carts.

     Ability to sit for long periods of time, manual dexterity and mobility for extensive use of

     computer screen, keyboard, copy and facsimile machines, reader/printer and other office

     equipment.

     Adequate to perform essential functions of the job with the type of judgments and potential

     consequences outlined above.

Knowledge of medical record documentation requirements coding guidelines.

 Related Computer knowledge of Epic a plus.

RN preferred or CCS, CPC or RHIT preferred.  

NJ-RN License (Registered Nurse) preferred CCS, CPE or RHIT preferred.

Essential mental abilities: good critical thinking skills, able to assess, evaluate and teach.

Requires excellent observation skills, analytical thinking, problem solving, computer skills, good verbal and  written communication.