Clinical Document Specialist

Job Title: Clinical Document Specialist

Location: System Business Office

Department: Clinical Documentation Mgmt (8255010)

Req#:  0000190492

Status: Full-Time

Shift: Day

Pay Range: $113,390.00 to $138,902.75 per year 

Pay Transparency:

The above pay range 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 Require:

• 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: Newark Beth Israel Medical Ctr - Newark, 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.