Nurse Clinical Documentation Specialist

St. Joseph's Health; Paterson (NJ); On-site; USD 95,000 - 125,000; Full time

Benefits offered by this job

Competitive salary

Health plans

Dental plans

Rx plans

Vision plans

403b retirement with match

Health & Wellness

PTO and holidays

Tuition reimbursement

Employee Assistance Program

Long Term Disability

Life Insurance

Onsite Day care

Per Diem & Part-time options

Job summary

St. Joseph’s Health in Paterson, NJ seeks a Clinical Documentation Specialist to improve the quality and completeness of medical records, reviewing charts, coordinating with physicians and the coding team to ensure accurate severity of illness.

This role requires a nursing background and 3–5 years of related experience. Certifications such as CCDS/CDIP/CCS (or RN with CCDS/CDIP within two years) are expected; a Master’s degree is preferred.

Qualifications

• Bachelor's degree in Nursing required; Master's degree preferred.
• Three to five years of related experience in Medical/Surgical, ICU, ED or PACU.
• RN or MD/MBBS and CCDS/CDIP/CCS certifications within two years of hire.

Responsibilities

• Facilitates improvement in documentation quality, completeness and accuracy.
• Reviews records and recommends opportunities for documentation improvement.
• Educates care team on documentation guidelines and ensures accurate severity of illness.

Skills

Clinical documentation

Communication

Team collaboration

Education

Bachelor's degree in Nursing

Master's degree preferred

RN license

CCDS

CDIP

CCS

Job description

Job Description

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical records documentation. Reviews and recommends opportunities for documentation improvement through extensive record review. Obtains appropriate clinical documentation through extensive interaction with physicians, patient care providers and the coding team to ensure the clinical documentation reflects the level of service rendered to the patient is complete and accurate. Educates members of the patient care team regarding documentation guidelines on an ongoing basis. Demonstrates knowledge and skills necessary to assign an accurate severity of illness.

Qualifications

Work requires the knowledge of theories, principles and concepts normally acquired through completion of a Bachelor's degree in Nursing, Masters degree preferred, and three to five years of previous work related experience in Medical/Surgical, Intensive Care, Emergency Department, or PACU. Medical school graduate (MD, MBBS) or Registered Nurse (RN) and Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Integrity Specialists or Certified Documentation Integrity Practitioner (CDIP) or Certified Coding Specialist (CCS) by the American Health Information Management Association within two years or hire.

About Us

St. Joseph’s Health is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization’s outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation’s “100 Best Places to Work in Health Care”.

Benefits Eligibility

• Competitive salary*
• Robust benefits with health, dental, Rx and vision plans
• 403b retirement plan options with company match**
• Health & Wellness*
• Non-Profit Health System – eligible for Federal Student Loan Forgiveness
• PTO, and paid holidays
• Tuition reimbursement
• Employee Assistance Program
• LTD : Long Term Disability
• Life Insurance Options
• Onsite Day care Program
• Available for Per Diem Employees and Part-time Employees working under 20 hours per week.
• 403b Company Match not applicable for Per Diem Employees and Part-time Employees working under 20 hours per week.

Pay transparency

Pay transparency: St. Joseph’s Health provides a salary range to comply with New Jersey Law. The rate of pay for each position will be determined based on a variety of factors including the candidate's relevant experience, qualifications, skills, etc.”

About The Team

St. Joseph’s University Medical Center is an academic tertiary care medical center and state designated trauma center, located on the Paterson campus, regularly accepts referrals of difficult or unusual cases from other hospitals and physicians and performs both complex and routine procedures. The Medical Center offers a full complement of specialty and subspecialty services including ambulatory, behavioral health, cardiovascular, emergency/trauma, internal medicine, neuroscience, oncology, orthopedic/spine, rehabilitation, surgical specialty, women’s health, imaging and pediatrics. The nursing team at St. Joseph’s University Medical Center, which includes St. Joseph’s Children’s Hospital, has held the Magnet Award for Nursing Excellence, the profession’s highest honor, since 1999. They are also recipients of the prestigious 2010 Magnet Prize - one of only 8 Magnet-designated hospitals to ever receive The Magnet Prize, and the only one worldwide to receive the 2010 award.