RN Clinical Documentation Specialist: Elevate Care

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

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