CDI Specialist: Elevate Documentation & Compliance

Hudson Regional Hospital; Bayonne (NJ); On-site; USD 34,000 - 48,000; Full time

Job summary

Hudson Regional Hospital in Bayonne, NJ is seeking a Clinical Documentation Specialist to ensure accuracy and completeness of medical records. You will collaborate with clinicians and coding teams to clarify documentation and support compliant billing.

The role emphasizes CDI initiatives, education of staff, and monitoring documentation trends to improve care quality and regulatory adherence. 2+ years in CDI and relevant certifications are preferred.

Qualifications

• Bachelor's degree or higher in a healthcare field.
• CCDS or equivalent certification preferred.
• Minimum 2 years in clinical documentation, health information management, or related role.
• Strong knowledge of ICD-10 and CPT coding systems.
• Excellent communication with clinical and administrative staff.

Responsibilities

• Review and analyze clinical documentation for accuracy and regulatory compliance.
• Collaborate with physicians, nurses, and staff to clarify and improve documentation.
• Educate clinical staff on documentation best practices and regulatory requirements.
• Assist in CDI initiatives and policy development.
• Monitor documentation trends and provide feedback to stakeholders.

Skills

Medical terminology

Excellent communication

Clinical workflows

ICD-10/CPT knowledge

Education

Bachelor's degree in Nursing or Health Information Management

CCDS certification or equivalent

RHIA/RHIT (preferred)

Tools

EHR systems

Clinical documentation software

Job description

Hudson Regional Hospital in Bayonne, NJ is seeking a Clinical Documentation Specialist to ensure accuracy and completeness of medical records. You will collaborate with clinicians and coding teams to clarify documentation and support compliant billing.

The role emphasizes CDI initiatives, education of staff, and monitoring documentation trends to improve care quality and regulatory adherence. 2+ years in CDI and relevant certifications are preferred.