Clinical Document Specialist - PD

Holy Name Medical Center; Teaneck Township (NJ); On-site; USD 110,814,000 - 149,387,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision plans

401(k) matching

Tuition reimbursement

Paid time off

Flexible spending accounts

Life insurance

On-site parking

Job summary

Holy Name Medical Center is seeking a knowledgeable Clinical Documentation Specialist to support improved medical record documentation. You will review clinical information for accurate representation of illness severity and collaborate with physicians, HIM staff, and nursing to ensure discharge diagnoses and comorbidities are fully captured.

In this role, you will input data into CDMP Trak, participate in education initiatives, and drive timely documentation improvements across departments.

Qualifications

• Bachelor's Degree Required.
• Master's Degree Preferred.
• 4-6 years of clinical experience Required.

Responsibilities

• Learn/develop the skills to perform CDMP.
• Conduct accurate and timely record review.
• Identify opportunities for documentation improvement.
• Formulate clinically credible documentation clarifications.
• Communicate effectively with physicians.
• Follow up on cases with clarifications.
• Participate in Task Force Meetings.
• Resolve discrepancies with HIM staff.
• Input data into CDMP Trak accurately.
• Perform additional duties as assigned.

Skills

Organizational skills

Analytical skills

Writing skills

Interpersonal skills

Basic computer skills

Medicare knowledge

Pathophysiology knowledge

Regulatory knowledge

Education

Bachelor's degree

Master's degree

Tools

CDMP Trak

Job description

Location: Teaneck, NJ, United States Date Posted: Aug 12, 2026

Welcome to Holy Name, a medical center where innovation is not just a goal — it's a commitment. Here, medical excellence thrives, allowing hope to reign supreme and leaving no room for fear. At our hospital, every patient is cared for with undivided attention — because healing every soul is our sole focus. Holy Name is New Jersey's only independent Catholic health system, comprising a 361-bed acute care hospital, a renowned cancer center, a state‑of‑the‑art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through graduate medical education, a Pharmacy Residency Program, and our Institute for Simulation Learning. Our mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness. This is at the core of who we are and what we do, and we've done it this way across generations, every single day, for nearly 100 years. Every innovation, medical breakthrough, and groundbreaking treatment is powered by some of the best minds in medicine, ensuring nothing is left on the table or the road to recovery.

A Brief Overview

The CDS facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Responsible for analyzing clinical information for accurate representation of the severity of illness. This involves extensive medical record review, interaction with physicians, HIM professionals and nursing staff. Must work collaboratively with coding staff to assure documentation of discharge diagnosis and co‑morbidities are a complete reflection to the patient's clinical status and care. Active participation in team meetings for development and implementation of education for physicians, nurses and ancillary staff on documentation improvement.

What you will do

• Able to learn/develop the skills necessary to perform CDMP®
• Conducts accurate and timely record review
• Recognizes opportunities for documentation improvement
• Formulates clinically credible documentation clarifications
• Effectively and appropriately communicates with physicians
• Performs timely follow up on all cases, especially those with clinical documentation clarifications
• Participates in Task Force Meetings
• Communicates with HIM staff and resolves discrepancies
• Accurately inputs data into CDMP Trak®
• Performs additional duties as assigned

Education Qualifications

• Bachelor's Degree Required and
• Master's Degree Preferred

Experience Qualifications

• 4-6 years of clinical experience Required

Knowledge, Skills, and Abilities

• Organizational, analytical, writing, and interpersonal skills;
• Basic computer skills;
• Knowledge of Medicare Parts A & B, pathophysiology, disease process, and the regulatory environment

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required

At Holy Name, we believe in rewarding every team member with more than a paycheck—we invest in your future and well-being. Full-time and part-time employees have access to a comprehensive benefits package designed to support your health, financial security, and quality of life. We offer low-cost medical coverage with generous employer contributions, dental and vision plans, discounted prescriptions, and access to on‑site child care. Additional benefits include 401(k) matching, tuition reimbursement, paid time off, flexible spending accounts, legal and voluntary coverage options, life insurance, and free on‑site parking. If you are hired at Holy Name, your final base compensation will be determined based on factors such as employment status (Full/Part-Time or Per Diem) skills, education, and/or experience. In addition to those factors – we believe in the importance of pay equity and consider any internal equity of our current team members as a part of any final offer. Pay Range: $45.50

Holy Name is a mission‑driven facility whose quality standards and philosophy are rooted in the principles of its founders, the Sisters of St. Joseph of Peace. Those principles are exercised daily by the Medical Center's dedicated and talented staff members. Holy Name is an Equal Opportunity Employer.