Clinical documentation improvement specialist - remote

Apply now

Location

remote, United States

Salary

$69k – $113k/yr

Commitment

Full Time

Level

Middle (2-4 years)

Required skills

Clinical documentation improvementMedical record reviewCoding complianceDRG accuracyPhysician queryMedical necessityClinical auditingHealthcare communicationDocumentation analysisClinical severityHIM leadership collaborationMedical terminology

Job Description

About Us

Cooper Norcross Health, formerly Cooper University Health Care, is a leading academic health system affiliated with Cooper Medical School of Rowan University. Headquartered in Camden, New Jersey, Cooper Norcross Health has revenues of more than $3 billion and an A+ credit rating from both S&P and Fitch Ratings.

Cooper Norcross Health has nearly 14,000 team members, including more than 2,200 nurses, more than 1,200 employed physicians representing 95 specialties and subspecialties, and more than 700 advanced practice providers.

The health system operates MD Anderson Cancer Center at Cooper as well as four hospitals – its 663-bed flagship Cooper Norcross University Hospital in Camden, its 229-bed Cooper Norcross University Hospital Cape Regional in Cape May Court House, Children’s Hospital at Cooper Norcross Health in Camden, and The Recovery Village Cherry Hill at Cooper, a substance abuse rehabilitation and inpatient treatment facility, in partnership with Advanced Recovery Systems.

Cooper Norcross University Hospital in Camden is the only Level 1 Trauma Center in South Jersey and the busiest in the region. The hospital has been recognized as a top-performing regional hospital by U.S. News & World Report’s Best Hospitals annual survey for eight years.

More than 2.54 million patients visit Cooper Norcross Health facilities annually. Its ambulatory network encompasses three outpatient surgery centers, seven urgent care centers, a wound care center, and more than 130 physician, physical therapy, and radiology offices extending from the Delaware River to the New Jersey shore.

Cooper Norcross Health, a not-for-profit health system, was named one of America’s Best Large Employers for 2026 by Forbes, ranking among the top 200 in the nation. Visit CooperHealth.org(opens in new window) to learn more.

Short Description

Uses clinical expertise to review patient medical records and ensure that the documentation accurately reflects the patient’s diagnosis, treatments and severity of illness. This role bridges the gap between healthcare providers and coding professionals, ensuring that medical records are complete, compliant, and support proper reimbursement.

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.

Ready to join the team?

Apply now