Clinical Documentation Specialist RN

Hackensack Meridian Health; Hackensack (NJ); On-site; USD 90,000 - 120,000; Full time

Job summary

Hackensack Meridian Health seeks a Clinical Documentation Specialist RN to improve medical record documentation quality, completeness and accuracy across the northern region. The CDS educates physicians, nursing staff and HIM personnel to ensure documentation reflects the level of service provided.

Requirements include a Bachelor’s degree in Nursing, an active RN license, 5+ years of clinical experience (ICU/ED preferred), strong communication and analytical skills, and CCDS certification or

Qualifications

• Bachelor's degree in Nursing is required.
• Active RN license in good standing.
• Minimum 5 years of clinical experience, ICU/ED preferred.
• Excellent communication and analytical skills.
• Ability to educate and collaborate with physicians and staff.
• CCDS certification or eligibility within 2 years.

Responsibilities

• Improve quality, completeness and accuracy of medical record documentation.
• Educate care teams on documentation guidelines ongoingly.
• Review ED inpatient admissions and observations for accuracy.
• Coordinate with HIM, case managers and ED staff for proper documentation.
• Support CDMP documentation strategies and regulatory requirements.

Skills

Communication skills

Analytical thinking

Interpersonal skills

Problem solving

Organizational skills

Self-directed

Critical thinking

Time management

Education

Bachelor's degree in Nursing

Registered Nurse (RN) license

Advanced Practice Degree

Tools

Microsoft Word

Excel

Job description

Our team members are the heart of what makes us better.

At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Clinical Documentation Specialist RN facilitates improvement in the overall quality, completeness and accuracy of medical record documentation for assigned hospital in the northern region of Hackensack Meridian Health (HMH). Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department (ETD), to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis. The CDS reviews and screens ED inpatient admissions and observations as specified by the facility's Utilization Management/Review Committee for documentation completeness and compliance with patient status. Facilitates accurate documentation for severity of illness and medical necessity. Interacts with physicians, case managers, and nursing staff and provides guidance and recommendations for admission or observation disposition. The CDS assesses patients for present-on-admission (POA) conditions to ensure accurate documentation, regarding hospital acquired conditions (HAC). Communicates the transfer of appropriate concurrent information to the inpatient Case Managers and the Clinical Documentation Specialists (CDS), assigned to the unit.

Education, Knowledge, Skills and Abilities Required:

• Graduation from a bachelor's level program of Nursing (or in select cases, may allow to obtain within 2 years of hire).
• Minimum of 5 or more years of recent clinical experience, preferably in Medical/Surgical Critical Care, Intensive Care or Emergency Room Care.
• Ability to interact well with physicians and other members of allied health care team, including HIM coders.
• Must be computer literate, have working knowledge and familiarity of Microsoft Word and Excel/Windows based software programs.
• Must possess excellent communication, organizational, analytical, writing and interpersonal skills.
• Dependable, self-directed and pleasant.
• Critical thinking, problem solving and deductive reasoning skills.
• Recent hospital experience.
• Knowledge of Pathophysiology and Disease Process.
• Knowledge of Medicare Part A.
• Familiar with Medicare Part B.
• Knowledge of regulatory environment.
• Understand and support CDMP® documentation strategies.
• Knowledge of POA/HAC and core measures.
• Knowledge of Observation and Inpatient medical necessity.
• Knowledge of regulatory requirements for appropriateness of admissions.

Education, Knowledge, Skills and Abilities Preferred:

• Advanced Practice Degree.
• ICU, CCU and/or strong Medical/Surgical experience.

Licenses and Certifications Required:

• Current state Registered Nurse license.
• Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility.