Clinical Document Specialist - Trenton - RWJBarnabas Health Corporate Services

    RWJBarnabas Health Corporate Services
    RWJBarnabas Health Corporate Services Trenton

    23 hours ago

    Description

    Job Title:
    Clinical Document Specialist


    Location:
    Barnabas Health Corp


    Department:
    Clinical Documentation Mgmt


    Req#:

    Status:
    Full-Time


    Shift:
    Day


    Pay Range:
    $91, $129,204.00 Annual


    Pay Transparency:
    The above reflects the anticipated annual salary range for this position if hired to work in New Jersey.

    The compensation offered to the candidate selected for the position will depend on several factors, including the candidate's educational background, skills and professional experience.


    Job Overview:


    A clinical documentation specialist (CDS) reviews a patient's medical records to ensure documentation is accurate as well as up-to-date with the latest information on a patient's illness.

    They also record the details of every step-in clinical treatment.

    A CDS must have familiarity with the codes involved with medical records, each of which is used to indicate some aspect of the patient's medical information, condition and the treatment received.

    A CDS must have the clinical knowledge to talk with doctors, nurses and other healthcare providers about the treatment a patient has received, especially if there are gaps in the healthcare record.


    Qualifications:


    Required:
    Graduate from an accredited school of nursing with a BSN degree
    Minimum 5 years acute hospital experience as a clinical nurse
    Must read, write and speak English.
    Passing grade on Clinical Competency Exam
    Advanced understanding of anatomy, physiology, pathophysiology, and pharmacology
    Excellent interpersonal, oral and written communication and organizational skills
    Must maintain a professional demeanor
    Must display a proven analytical capability
    The ability to work independently with minimal supervision
    Able to quickly learn new concepts and software


    Preferred:
    CCDS certification (preferred)
    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

    Certifications and Licenses

    Required:
    Current New Jersey Licensed Registered Nurse


    Scheduling Requirements:

    Working Hours:
    Hybrid - four days onsite, one day remote. Subject to change based on business needs.

    Physical Working Location:
    Monmouth Medical Center in Long Branch, NJ

    Essential Job Functions
    Concurrently review and evaluate selected patient's medical records for overall quality and completeness
    Assisting in clarifying documentation regarding the patient's diagnoses and/or procedures, co-morbid conditions, complications, and other reportable data elements including quality measures and severity of illness and risk of mortality (SOI/ROM)
    Clarifications will be completed by utilizing computer software to generate the clarification.

    Collaborate with physicians, non-physician clinicians, coding professionals on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities.


    Other Duties:


    Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

    At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees' physical, emotional, social, and financial health.

    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 our Partners such as NJ Devils, NJ PAC, Verizon, and more
    Choosing RWJBarnabas Health
    RWJBarnabas Health is the premier health care destination providing patient-centered,
    high-quality academic medicine in a compassionate and equitable manner, while delivering
    a best-in-class work experience to every member of the team.

    We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time.

    As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

    RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey.

    From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state.

    We understand the growing and evolving needs of residents in New Jersey—whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

    Equal Opportunity Employer
    #LI-AB1

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