Clinical Documentation Improvement Specialist (RN)

Capital Health; New Jersey; On-site; USD 54,000 - 70,000; Full time

Benefits offered by this job

Retirement Savings and Investment Plan

Disability Benefits – STD

Sick Time Off

Employee Assistance Program

Job summary

Capital Health seeks a Clinical Documentation Specialist to improve the quality and completeness of clinical documentation across patient records, ensuring accurate DRG assignments and quality reporting. Strong communication with physicians and care teams is essential.

Two years of acute care experience or three years of coding/clinical documentation improvement in a hospital setting is required. CCDS or CDIP is preferred. Excellent documentation accuracy and collaboration are valued.

Qualifications

• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators.
• Excellent verbal and written communication skills.
• Working knowledge of all areas of adult medicine; knowledge of pathophysiology and disease processes.

Responsibilities

• Completes initial reviews of patient records within 24-48 hours of admission to evaluate documentation for accurate DRG assignment, risk of mortality, and severity of illness.
• Conducts follow-up reviews of patients every 2-3 days to support final DRG assignment at discharge.
• Queries physicians regarding missing or unclear documentation to obtain additional documentation.
• Educates physicians and healthcare providers regarding clinical documentation improvement and documentation guidelines.

Skills

Critical thinking

Verbal and written communication

EMR systems familiarity

Problem-solving

Education

RN license

BSN preferred

Tools

Windows-based software

Encoding software

EMR systems

Job description

Capital Health seeks a Clinical Documentation Specialist to improve the quality and completeness of clinical documentation across patient records, ensuring accurate DRG assignments and quality reporting. Strong communication with physicians and care teams is essential.

Two years of acute care experience or three years of coding/clinical documentation improvement in a hospital setting is required. CCDS or CDIP is preferred. Excellent documentation accuracy and collaboration are valued.