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    Clinical Document Specialist, Clinical Documentation Management

    Rwj Barnabas Health
    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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