Nurse Clinical Documentation Specialist

Jobtailor; Paterson (NJ); On-site; USD 90,000 - 130,000; Full time

Job summary

Jobtailor is seeking a Clinical Documentation Specialist to enhance the quality and accuracy of medical records. You will review records, interact with physicians and coding teams, and educate care teams on documentation guidelines to ensure complete and accurate clinical documentation.

The role requires nursing background (RN) or medical doctorate, with CCDS/CDIP/CCS certifications encouraged within two years of hire. Strong collaboration and documentation accuracy are essential.

Qualifications

• Bachelor's degree in Nursing required.
• Master's degree preferred.
• 3–5 years of experience in Medical/Surgical, Intensive Care, Emergency Department, or PACU.
• MD/MBBS or RN required.
• CCDS/CDIP/CCS certification within two years or upon hire.
• Knowledge of theories, principles, and concepts related to clinical documentation.
• Ability to review medical records and assign accurate severity of illness.

Responsibilities

• Ensure clinical documentation reflects the level of service rendered and is complete and accurate.
• Educate patient care team members on documentation guidelines on an ongoing basis.
• Interact extensively with physicians, patient care providers, and the coding team.
• Assign accurate severity of illness.

Skills

Clinical Documentation Improvement

Medical Record Review

Documentation Guidelines

Severity of Illness Assignment

Quality Improvement

Education

Bachelor's in Nursing

Master's degree

MD/MBBS or RN

Job description

Facilitate improvement in the overall quality, completeness, and accuracy of medical record documentation
Review records and recommend opportunities for documentation improvement
Interact extensively with physicians, patient care providers, and the coding team
Ensure clinical documentation reflects the level of service rendered and is complete and accurate
Educate patient care team members on documentation guidelines on an ongoing basis
Assign accurate severity of illness

Requirements

• Bachelor's degree in Nursing required
• Master's degree preferred
• 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)
• Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Integrity Specialists, Certified Documentation Integrity Practitioner (CDIP), or Certified Coding Specialist (CCS) by the American Health Information Management Association within two years or hire
• Knowledge of theories, principles, and concepts related to clinical documentation
• Ability to review medical records and assign accurate severity of illness

Core Competencies

Demonstrates expertise in clinical documentation improvement, ensuring accuracy and completeness of medical records while educating healthcare teams on documentation guidelines. Proficient in assessing severity of illness and collaborating with medical professionals to enhance documentation practices.

Highest-signal resume keywords

• Clinical Documentation Improvement
• Medical Record Review
• Certified Clinical Documentation Specialist (CCDS)
• Registered Nurse (RN)
• Severity of Illness Assessment

Hard Skills

• Clinical Documentation
• Medical Record Review
• Documentation Guidelines
• Severity of Illness Assignment
• Quality Improvement

Soft Skills

• Interpersonal Communication
• Team Collaboration
• Education and Training

Certifications & Qualifications

• Certified Clinical Documentation Specialist (CCDS)
• Certified Documentation Integrity Practitioner (CDIP)
• Certified Coding Specialist (CCS)

Industry Keywords

• Medical/Surgical
• Intensive Care
• Emergency Department
• PACU
• Clinical Documentation Integrity