Nurse Clinical Documentation Specialist

St. Joseph's Health•NJ, NJ

7d•$55 - $77•Onsite

About The Position

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness, and accuracy of medical records documentation. This role involves reviewing and recommending opportunities for documentation improvement through extensive record review. The specialist obtains appropriate clinical documentation through extensive interaction with physicians, patient care providers, and the coding team to ensure the clinical documentation accurately reflects the level of service rendered to the patient. Additionally, the role includes educating members of the patient care team regarding documentation guidelines on an ongoing basis and demonstrating the knowledge and skills necessary to assign an accurate severity of illness.

Requirements

Knowledge and skills necessary to assign an accurate severity of illness.

Responsibilities

Facilitate improvement in the overall quality, completeness, and accuracy of medical records documentation.
Review and recommend opportunities for documentation improvement through extensive record review.
Obtain appropriate clinical documentation through extensive interaction with physicians, patient care providers, and the coding team.
Ensure clinical documentation reflects the level of service rendered to the patient and is complete and accurate.
Educate members of the patient care team regarding documentation guidelines on an ongoing basis.
Demonstrate knowledge and skills necessary to assign an accurate severity of illness.