RN Clinical Documentation Specialist: Elevate Care

Hackensack Meridian Health; Hackensack (NJ); On-site; USD 87,000 - 107,000; Full time

Job summary

Hackensack Meridian Health is seeking a Clinical Documentation Specialist RN to improve the completeness and accuracy of medical record documentation across its northern region. You will educate physicians, nurses, and staff on documentation guidelines and collaborate with HIM/coding teams to ensure clinical documentation reflects level of service and severity of illness.

The role requires an RN license, 5+ years of clinical experience, and CCDS certification (preferred).

Qualifications

• Graduation from a bachelor’s program in Nursing and an active RN license.
• Minimum 5+ years of clinical experience preferred, in hospital settings.
• CCDS certification preferred or within two years of eligibility.
• Proficient in Word/Excel; strong documentation and analytical skills.

Responsibilities

• Improve documentation quality and accuracy for assigned hospital units.
• Educate care teams on documentation guidelines on an ongoing basis.
• Review admissions, records, and treatments to ensure accuracy and compliance.
• Collaborate with physicians, case managers, and HIM/coding staff.
• Maintain and update DRG/POA-related documentation; participate in MDT rounds.

Skills

Nursing

Communication skills

Interpersonal skills

Computer literacy

Education

Bachelor's degree in Nursing

CCDS certification (preferred)

Tools

Microsoft Word

Microsoft Excel

Job description

Hackensack Meridian Health is seeking a Clinical Documentation Specialist RN to improve the completeness and accuracy of medical record documentation across its northern region. You will educate physicians, nurses, and staff on documentation guidelines and collaborate with HIM/coding teams to ensure clinical documentation reflects level of service and severity of illness.

The role requires an RN license, 5+ years of clinical experience, and CCDS certification (preferred).