RN Clinical Documentation Specialist: Elevate Patient Records

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

Job summary

Hackensack Meridian Health seeks an experienced Clinical Documentation Specialist Registered Nurse to improve the quality and completeness of medical record documentation for the northern region. The CDS will interact with physicians, nursing staff and HIM coders to ensure accurate documentation reflecting care level and medical necessity.

The role requires active RN licensure, 5+ years of clinical practice (ICU/ED preferred) and CDS education, with CCDS preferred within two years.

Qualifications

• Bachelor's degree in Nursing; active RN license.
• Minimum 5+ years of recent clinical experience, preferably Medical/Surgical, Critical Care or Emergency care.
• CCDS certification preferred within two years of eligibility.
• Strong communication and education skills for physicians and staff.
• Proficient with Microsoft Word and Excel in a clinical documentation setting.

Responsibilities

• Educates patient care team on documentation guidelines and ongoing CDS education.
• Reviews and screens ED inpatient admissions and observations for documentation completeness.
• Collaborates with physicians to clarify documentation opportunities and needs.
• Reviews medical records to ensure accuracy of severity of illness, medical necessity and POA status.
• Coordinates with HIM coders to assign accurate DRG and CDMP/3M 360 entries.
• Maintains ongoing CDS education and participates in multidisciplinary rounds.

Skills

Clinical Documentation

RN

CCDS

Word/Excel

Healthcare coding

Education

Bachelor's degree in Nursing

Tools

CDMP®

3M 360

Job description

Hackensack Meridian Health seeks an experienced Clinical Documentation Specialist Registered Nurse to improve the quality and completeness of medical record documentation for the northern region. The CDS will interact with physicians, nursing staff and HIM coders to ensure accurate documentation reflecting care level and medical necessity.

The role requires active RN licensure, 5+ years of clinical practice (ICU/ED preferred) and CDS education, with CCDS preferred within two years.