CDI RN - 249494

Medix™; Oceanport (NJ); On-site; USD 65,000 - 85,000; Full time

Job summary

A healthcare company is seeking a Clinical Documentation Specialist based in Oceanport, New Jersey. The successful candidate will ensure that patient medical records are accurate and updated according to the latest treatment information. Responsibilities include promoting quality care by adhering to physician standards and providing patient education. Candidates must be a Registered Professional Nurse, hold certifications in CPR, ACLS, and BCLS, and possess knowledge of compliance regulations including OSHA, FDA, and HIPAA.

Qualifications

• Must be a Registered Professional Nurse with current licensure.
• CPR, ACLS, and BCLS Certification required.
• Knowledge of OSHA, FDA, and HIPAA compliance necessary.

Responsibilities

• Assure quality care by adhering to standards set by physicians.
• Provide care education to patients in person or over the phone.
• Adhere to compliance guidelines throughout processes.

Skills

Clinical knowledge

Compliance knowledge (OSHA, FDA, HIPAA)

Patient care education

Education

Registered Professional Nurse with current licensure

Tools

CPR Certification

ACLS Certification

BCLS Certification

Job description

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.

Responsibilities

• Assure quality care by adhering to standards set by the physicians
• Provide care education to patients in person or over the phone
• Adhere to compliance guidelines throughout processes (OSHA, FDA, HIPAA)

Qualifications

• Must be a Registered Professional Nurse with current licensure
• CPR, ACLS, and BCLS Certification
• Knowledge of OSHA, FDA, and HIPAA compliance
• Candidate must be able to lift and position patients on endoscopy stretcher and transport patients