CDI Specialist: Elevate Care with Precise Documentation

Hudson Regional Health; Bayonne (NJ); On-site; USD 70,000 - 100,000; Full time

Job summary

Hudson Regional Health in New Jersey seeks a Clinical Documentation Specialist to improve the accuracy and completeness of medical records, support coding/billing, and ensure regulatory compliance.

You will review records, clarify documentation with clinicians, educate staff on best practices, and help implement CDI initiatives to enhance patient care, reimburse­ment accuracy, and data integrity across the organization.

Qualifications

• Bachelor’s degree in Nursing, Health Information Management, or related healthcare field.
• CCD S credentials preferred or equivalent certification.
• Minimum of 2 years of experience in clinical documentation or related role.
• Strong knowledge of medical terminology, clinical workflows, and ICD-10/CPT coding.
• Excellent communication skills interacting with clinical and administrative staff.

Responsibilities

• Review and analyze clinical documentation to ensure completeness, accuracy, and regulatory compliance.
• Collaborate with physicians, nurses, and healthcare professionals to clarify and improve documentation.
• Educate clinical staff on documentation best practices and regulatory requirements to enhance quality.
• Assist in development and implementation of CDI initiatives and policies.
• Monitor and report documentation trends and provide feedback to stakeholders.

Skills

Communication skills

Medical terminology

ICD-10/CPT knowledge

Education

Bachelor’s degree in Nursing/Health Information Management

RHIA/RHIT certification

Job description

Hudson Regional Health in New Jersey seeks a Clinical Documentation Specialist to improve the accuracy and completeness of medical records, support coding/billing, and ensure regulatory compliance.

You will review records, clarify documentation with clinicians, educate staff on best practices, and help implement CDI initiatives to enhance patient care, reimburse­ment accuracy, and data integrity across the organization.