Job Description

Job Overview:

A clinical documentation specialist (CDS) reviews a patient s medical records to ensure documentation is accurate as well as up-to-date with the latest information on a patient s illness. They also record the details of every step-in clinical treatment. A CDS must have familiarity with the codes involved with medical records, each of which is used to indicate some aspect of the patient s medical information, condition and the treatment received. A CDS must have the clinical knowledge to talk with doctors, nurses and other healthcare providers about the treatment a patient has received, especially if there are gaps in the healthcare record.

Qualifications:

Required:

• Graduate from an accredited school of nursing with a BSN degree
• Minimum 5 years acute hospital experience as a clinical nurse
• Must read, write and speak English.
• Passing grade on Clinical Competency Exam
• Advanced understanding of anatomy, physiology, pathophysiology, and pharmacology
• Excellent interpersonal, oral and written communication and organizational skills
• Must maintain a professional demeanor
• Must display a proven analytical capability
• The ability to work independently with minimal supervision
• Able to quickly learn new concepts and software

Preferred:

• CCDS certification (preferred)
• Prior experience in clinical documentation review
• Understanding of ICD-10-CM coding requirements
• Experience in a supervisory role
• Adult acute care experience in med/surg, critical care, emergency, or PACU

Certifications and Licenses Require:

• Current New Jersey Licensed Registered Nurse

Scheduling Requirements:

• Working Hours: Hybrid - four days onsite, one day remote
• Physical Working Location: The physical working location for this role will be one of the following: CBMC, CMMC, CMC, JCMC, NBI, RWJUH, RWJS

Essential Job Functions

• Concurrently review and evaluate selected patient's medical records for overall quality and completeness
• Assisting in clarifying documentation regarding the patient s diagnoses and/or procedures, co-morbid conditions, complications, and other reportable data elements including quality measures and severity of illness and risk of mortality (SOI/ROM)
• Clarifications will be completed by utilizing computer software to generate the clarification.
• Collaborate with physicians, non-physician clinicians, coding professionals on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.

• Paid Time Off (PTO)
• Medical and Prescription Drug Insurance
• Dental and Vision Insurance
• Retirement Plans
• Short & Long Term Disability
• Life & Accidental Death Insurance
• Tuition Reimbursement
• Health Care/Dependent Care Flexible Spending Accounts
• Wellness Programs
• Voluntary Benefits (e.g., Pet Insurance)
• Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered,

high-quality academic medicine in a compassionate and equitable manner, while delivering

a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

Equal Opportunity Employer

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