Role Description BJC is hiring for a Clinical Documentation Coordinator. This role is responsible for reviewing medical records or reports, using Excel to create reports. Must have Epic, Excel, and report writing experience. This is a remote position. Responsibilities - Reviews and audits medical record documentation against Federal and State regulatory compliance requirements. - Accurately collects and compiles data in support of regulatory survey action plans, hospital audit requirements, and any clinical documentation related requests for information for executive level reporting to BJC System committees, BJC reporting dashboards, BJC & HSO Regulatory Committees, etc. - Assists Clinical Documentation Specialists in ensuring the integrity of the medical record accurately reflects clinical documentation has been thoroughly and timely recorded. - Maintains and collaborates to complete collection of clinical documentation data to support timely reporting to Regulatory Teams, Hospital Leadership and other applicable teams focused on ensuring compliant clinical documentation. Qualifications - High School Diploma or GED - Experience: Less than 2 years Preferred Qualifications - Education: Associate or Trade School Equivalent - Experience: 2-5 years - Licenses & Certifications: Registered Health Info Tech Benefits - Comprehensive medical, dental, vision, life insurance, and legal services available first day of the month after hire date - Disability insurance paid for by BJC - Annual 4% BJC Automatic Retirement Contribution - 401(k) plan with BJC match - Tuition Assistance available on first day - BJC Institute for Learning and Development - Health Care and Dependent Care Flexible Spending Accounts - Paid Time Off benefit combines vacation, sick days, holidays and personal time - Adoption assistance

• leading the development of high-quality and on-time clinical study documents • clinical document planning, writing, editing/formatting, and performing QC review • develops documents in compliance with Precision MW Style Guide, Precision SOPs, applicable regulatory guidelines (ie, ICH, FDA, GCP) and eCTD requirements • ensures smooth and effective document management from start to finish (ie, from template to final, approved version) • ability to independently formulate key messages from clinical study data • contributes to the development and maintenance of medical writing processes, SOPs, templates, and work instructions for key documents • performing literature-based research to support writing activities

• Conduct detailed home health and hospice pre-billing reviews to support Portfolio partners and their agencies. • Identify discrepancies, missing information, and opportunities for documentation improvement. • Utilize information gathered to provide education and facilitate alterations to the HCHB documentation, and process improvements to prevent recurrence. • Direct agencies to use documentation data outcomes for QA improvements. • Ensure documentation accurately reflects the patient’s clinical status and the care provided. • Set up meetings with clinical leaders to provide education, highlight findings, and make documentation recommendations. • Stay current with practices in both home health and hospice fields and suggest educational and resource materials which would be beneficial to the staff. • Recommend new approaches to on-going continued improvements to policies, procedures, and documentation. • Identify trending issues and share them with the team and the clinical leaders. • Stay up to date with all federal, state, and local regulations, as well as organizational policies and procedures to ensure compliance. • Work within and be comfortable with HCHB, PDF-Xchange, Excel, and Smartsheet.

Role Description Under the direction of CDI Manager, the Clinical Documentation Specialist reviews medical records to facilitate accurate and complete medical record documentation to reflect clinical treatment, decisions, and diagnoses used for measuring and reporting hospital and physician outcomes. Accurately identifies additional documentation opportunities and places appropriate queries and/or communicates with physicians, coders, and other health team members for documentation improvement. Works independently and works primarily in an approved remote home work environment. - Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson. - Accurately reviews medical records concurrently for completeness in documentation of diagnostic and procedural information for compliance to CMS, DOH regulatory, and financial requirements. - Assures documentation of diagnoses, procedures, co-morbid, and complication conditions are reflected on the medical record to support proper severity of illness, intensity of service, and risk of mortality classifications and designated quality reviews. - Prepares well written and compliant queries to communicate with physicians and other providers regarding missing, incomplete or clarifying information needed in the medical record. - Works closely with coding staff to assure that documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care. - Interacts and continuously educates physicians, nurse practitioners, and physician assistants. - Provides real-time intervention/education when needed to promote correct coding, regulatory compliance, and correction of documentation deficiencies. - Competent in utilizing all computer applications, e.g., Epic EHR, 3M DRG, MS Office. - Maintains productivity expectations and accurately records activity in CDI software tracking tool. - Demonstrates working effectively and independently in a remote home work environment, and effectively troubleshoots systems issues in accordance with department policy and procedures. - Tracks and trends issues identified during concurrent reviews. - Attends department meetings and actively contributes to the continued improvement and success of the department and the hospital. - Attends continuing education meetings, in-services, and training sessions related to coding and CDI to maintain skills and stay abreast of coding guideline changes and best practice CDI processes. - Demonstrates initiative, judgment, and creative ability in performance of job duties. - Identifies problems with process and suggests possible solutions. - Functions in a professional, efficient, and positive manner. - Performs other duties and assignments as necessary. Qualifications - Bachelor of Science in Nursing - Bachelor of Science in Health Information Management or related field - Certification, Associate or Bachelor in other healthcare related field with experience noted below Requirements - CCDS, CDIP certification preferred - RN/BSN preferred - RHIA, or RHIT with CCS, MD or DO will be considered - CCDS within 6 months of hire for eligible candidates - Maintenance of appropriate registration/certification - Responsible for tracking Continuing Education credits to maintain professional credentials if applicable Experience Requirements - Working knowledge of Medicare reimbursement system and coding structures preferred - 5 years of Critical Care/Emergency medicine or 5 years of Medical Surgical Experience preferred - 2-3 years Clinical Documentation Improvement experience or 5 years of Coding experience preferred - MD/DO with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered Benefits - Comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, and tuition assistance. - Access to voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. - Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service. - Access to medical (including prescription) insurance for all colleagues, including those who work less than part-time.