Responsible for ensuring the overall quality and completeness of medical record documentation.
Facilitates modifications to clinical documentation through concurrent interaction with
physicians, nursing staff, other patient caregiver and Health Information coding staff to
support that appropriate reimbursement and clinical severity is captured for the level of
service rendered to all inpatients.
Supports timely, accurate and complete documentation of clinical information used for
measuring and reporting physician and hospital outcomes.
Educates all members of the patient care team on an ongoing basis.
Professional team player, able to communicated well with others on all levels.
Regular significant contacts with other personnel throughout and outside the hospital.
Contacts may be in person, by telephone or through e-mail correspondence.
Flexible with a working knowledge of all areas of adult medicine.
Occasional lifting/carrying up to fifteen pounds, as well as reaching, stretching, stooping,
bending, kneeling, crouching, standing, walking and pushing/pulling to move and file
medical records alone or in carts.
Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of
computer screen, keyboard, copy and facsimile machines, reader/printer and other office
Adequate to perform essential functions of the job with the type of judgments and potential
consequences outlined above.
Scheduled Days / Hours: .; License (or Certification):NJ-RN Required
EPIC, JATA GUIDE software, 2 years minimum experience as Clinical Documentation Specialist in an acute setting.
Mandatory, no exceptions: CCDS, or CCS, or CDIP; Registered nurse – any state
Essential mental abilities: excellent critical thinking skills, able to assess, evaluate and teach. Must be self governed, disciplined, and organized.
Requires excellent work ethic, analytical thinking, problem solving, excellent computer skills, excellent verbal and written communication with knowledge of email etiquette . Must be proficient in Word, Excel, PowerPoint and typing (60 WPM)