Clinical Document Specialist, Clinical Documentation Management

2+ years

Not Disclosed

Livingston

10 July 3, 2024

Job Description

Job Type: Full Time Education: B.Sc./ M.Sc./ M.Pharm/ B.Pharm/ Life Sciences Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

Job Summary:

The Clinical Documentation Specialist (CDS) ensures accurate and compliant physician documentation in electronic medical records. Accurate documentation enhances reimbursement, improves quality outcomes, and facilitates disease tracking/trending.

Qualifications:

Required:

Graduate from an accredited school of nursing
Proficient in English (reading, writing, speaking)
Ability to work fully onsite
Experience in clinical documentation review preferred, along with an understanding of ICD-9-CM coding requirements
Passing grade on JATA clinical test
2+ years of acute hospital experience as a clinical nurse (ED, Critical Care, Telemetry, or Stepdown)
Successful completion of site personnel general orientation
Successful completion of department-specific orientation

Preferred:

Supervisory experience in any discipline
High-level clinical nurse experience

Certifications and Licenses Required:

Current Registered Nurse License in New Jersey
CDS certification desired
Basic Life Support (BLS) from the American Heart Association

Scheduling Requirements:

Full Time
Day shift
Monday to Friday, no holidays
Hours: 7 AM - 3 PM / 7:30 AM - 3:30 PM / 8 AM - 4 PM
37.5 hours weekly

Essential Functions:

Assist in clarifying documentation regarding patient diagnoses, procedures, co-morbid conditions, complications, and other reportable data elements.
Use computer software to generate physician clarifications when medical records are incomplete, inconsistent, unclear, ambiguous, or conflicting.
Write clarifications for various situations, including missing documentation of a condition, evidence of higher specificity or severity, cause-and-effect relationships, symptom-only admissions, treatment without diagnosis, POA indicator status, acuity of conditions, and conflicting documentation.
Ensure clarifications are not leading, concise, and precise, containing necessary facts from the medical record.
Capture Severity of Illness (SOI) and Risk of Mortality (ROM).
Use a 360-degree approach, including clinical indicators, treatment, and risk factors.
Document all physician clarification responses in primary sources of documentation such as face sheets, H&P, consultation notes, progress notes, and discharge summaries.

Other Duties: This job description is not exhaustive and may change at any time with or without notice.

Benefits and Perks: RWJBarnabas Health offers a market-competitive Total Rewards package supporting physical, emotional, social, and financial health, including:

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 partners like NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health:

RWJBarnabas Health is New Jersey’s premier health care destination, offering patient-centered, high-quality academic medicine in a compassionate and equitable manner. We provide a best-in-class work experience and strive to create healthier communities. As the leading academic health system in New Jersey, we innovate strategies in high-quality patient care, education, and research to address clinical and social health determinants.

We make a unique impact in local communities, enhancing residents’ health and creating educational and career opportunities. Our commitment includes treating complex health conditions and improving community health through local programs and education.

Equal Opportunity Employer

RWJBarnabas Health is an Equal Opportunity Employer.

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