Clinical Documentation Excellence Lead

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

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.