Nurse Clinical Documentation Specialist

St. Joseph's Health•Paterson, NJ

3d•$55 - $77•Onsite

About The Position

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical records documentation. Reviews and recommends opportunities for documentation improvement through extensive record review. Obtains appropriate clinical documentation through extensive interaction with physicians, patient care providers and the coding team to ensure the clinical documentation reflects the level of service rendered to the patient is complete and accurate. Educates members of the patient care team regarding documentation guidelines on an ongoing basis. Demonstrates knowledge and skills necessary to assign an accurate severity of illness.

Requirements

Bachelor's degree in Nursing
Three to five years of previous work related experience in Medical/Surgical, Intensive Care, Emergency Department, or PACU.
Medical school graduate (MD, MBBS) or Registered Nurse (RN)
Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Integrity Specialists or Certified Documentation Integrity Practitioner (CDIP) or Certified Coding Specialist (CCS) by the American Health Information Management Association within two years or hire.

Nice To Haves

Masters degree preferred

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 to ensure the clinical documentation reflects the level of service rendered to the patient 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.