Clinical Document Specialist
Not Disclosed•Full-TimeHybrid
location_onBrianna's Beauty Salon, John F. Kennedy Boulevard, Jersey City, Hudson County, New Jersey, 07306, United States
RWJBarnabas Health is the premier healthcare destination in New Jersey, providing patient-centered, high-quality academic medicine in a compassionate and equitable manner. As the leading academic health system in the state, we advance innovative strategies in patient care, education, and research to address both clinical and social determinants of health. Our mission is to create and sustain healthier communities, one person and one community at a time, by improving local resident health and creating educational and career opportunities.
As a Clinical Document Specialist within the Clinical Documentation Management department at Jersey City Medical Center, you will serve as a vital bridge between clinical care and accurate medical record-keeping. Your primary mission is to ensure that patient medical records are accurate, up-to-date, and reflective of the latest clinical information. You will review patient records to verify the completeness of documentation regarding diagnoses, procedures, co-morbid conditions, and complications.
In this role, you will utilize your clinical expertise to collaborate directly with physicians, non-physician clinicians, and coding professionals. You will clarify documentation gaps, ensuring that all reportable data elements, quality measures, and severity of illness indicators are accurately captured. This work is essential for supporting reimbursement, quality performance improvement, and the overall integrity of patient care data. You will work in a hybrid model, spending four days onsite at the Jersey City Medical Center and one day remotely, subject to business needs.
Candidates selected for this position will be evaluated based on their clinical background, specifically their experience as an acute hospital clinical nurse, and their ability to pass the Clinical Competency Exam. The interview process will focus on verifying your advanced understanding of anatomy, physiology, and pathophysiology, as well as your analytical capabilities and communication skills.
RWJBarnabas Health is an Equal Opportunity Employer. We are committed to creating a diverse and inclusive environment where all team members can thrive.
Work model: Hybrid
Brianna's Beauty Salon, John F. Kennedy Boulevard, Jersey City, Hudson County, New Jersey, 07306, United States
Jersey City, New Jersey
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.
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