RN CDI Specialist - Elevate Medical Documentation

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

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.