What are the responsibilities and job description for the Clinical Document Specialist position at RWJBarnabas Health Corporate Services?
Job Overview:
A clinical documentation specialist reviews a patient's medical records to ensure documentation is accurate and 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 codes involved with medical records, each of which is used to indicate some aspect of the patient's medical information, condition, and treatment received.
Key Responsibilities:
- Concurrently review and evaluate selected patient's medical records for overall quality and completeness
- Assist 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)
- 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
Requirements:
- 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 Qualifications:
- CCDS certification
- 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 Required:
- 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
Benefits:
- Market-competitive salary
- Comprehensive benefits package
- Tuition reimbursement
- Healthcare and dependent care flexible spending accounts
- Wellness programs
- Voluntary benefits (e.g., pet insurance)
- Discounts through partners such as NJ Devils, NJ PAC, Verizon, and more
About Us:
RWJBarnabas Health is a leading academic health system 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 advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.
We are committed to creating healthier communities by enhancing the coordination for treating complex health conditions and improving community health through local programs and education. As an equal opportunity employer, we strive to provide a diverse and inclusive environment where everyone feels valued and respected.