CLINICAL DOCUMENTATION SPECIALIST
JFK Johnson Rehabilitation Institute, Hackensack, New Jersey, us, 07601
Clinical Documentation Specialist – Hackensack University Medical Center, Hackensack, NJ
Requisition # 2025-174241 | Shift: Evening | Status: Part-time with Benefits
Overview Our team members are the heart of what makes us better. At Hackensack Meridian Health, we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.
The Clinical Documentation Specialist (CDS) facilitates improvement in the quality, completeness and accuracy of medical record documentation for the assigned hospital in the northern region of Hackensack Meridian Health. The CDS obtains and promotes appropriate clinical documentation through interaction with physicians, nursing staff, other patient caregivers, Health Information Management (HIM) coding staff, and Emergency Trauma Department (ETD), to ensure documentation reflects the level of service rendered is complete and accurate. The CDS educates all members of the patient care team on documentation guidelines on an ongoing basis. The CDS reviews ED inpatient admissions and observations as specified by the facility’s Utilization Management/Review Committee for documentation completeness and compliance with patient status, facilitates accurate documentation for severity of illness and medical necessity, and provides guidance for admission or observation disposition.
Responsibilities
Facilitate appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
Perform admission reviews for specific patient populations using clinical documentation guidelines.
Document appropriateness of patient admission, working DRG & LOS information on worksheet and computer system as appropriate.
Review physician and clinical documentation, lab results, diagnostic information and treatment plans and capture information on applicable documentation tools.
Identify documentation opportunities reflecting severity of illness, acuity and resource consumption; communicate with physicians to clarify opportunities.
Collaborate with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities.
Update DRG worksheets to reflect changes in patient status and procedures; finalize diagnoses with physicians.
Review medical records every 24-48 hours as appropriate and update documentation worksheets to reflect additional findings.
Communicate with physicians to ensure requests for documentation are noted and followed up; serve on multidisciplinary rounds as assigned.
Assist with follow-up reviews of clinical documentation, ensuring issues discussed are documented in the chart.
Document and analyze data; report instances of inappropriate patient care or discharge delays to the Director of Health Information.
Maintain ongoing education for new staff and participate in weekly educational conferences and performance improvement activities.
Collaborate with coding staff to determine appropriate DRG and required documentation; reconcile final coded DRG with the CDMP DRG at discharge.
Stay current with and educate others on the Clinical Documentation Management Program (CDMP) and related core measures and safety indicators.
Maintain positive communications with physicians and care teams; ensure documentation supports severity of illness and principal/secondary diagnoses.
Qualifications Education, Knowledge, Skills and Abilities Required
Graduation from medical school.
Minimum of 5 years of experience reviewing and screening inpatient admissions and observations or equivalent experience.
Experience improving medical records documentation quality and compliance.
Ability to interact well with physicians and allied health team members, including HIM coders.
Computer literate with working knowledge of Microsoft Word and Excel on Windows.
Excellent communication, organizational, analytical, writing and interpersonal skills.
Dependable, self-directed and pleasant; strong critical thinking, problem solving and deductive reasoning skills.
Recent hospital experience; knowledge of pathophysiology and disease processes.
Knowledge of Medicare Part A and Part B; regulatory environment; CDMP documentation strategies.
Understanding of POA/HAC and core measures; knowledge of admission appropriateness rules.
Education, Knowledge, Skills And Abilities Preferred
ICU/CCU and/or strong Medical/Surgical experience.
Licenses And Certifications
Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility.
Licenses And Certifications Preferred
CCDS or certification within two (2) years of eligibility.
Compensation and Benefits Starting at $47,777.60 Annually. Hackensack Meridian Health is committed to pay equity and transparency. The posted rate of pay is a reasonable good faith estimate of the minimum base pay for this role at the time of posting and does not reflect the full value of our total rewards package. Some jobs may be eligible for performance-based incentives, bonuses, or shift differentials.
HMH offers a comprehensive benefits package including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.
Equal Employment Opportunity Hackensack Meridian Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, genetic information, disability, marital status, veteran status, or other protected status.
Our Network: Hackensack Meridian Health is a mandatory influenza vaccination facility.
Apply and Connect If you are interested, please apply today.
#J-18808-Ljbffr
Overview Our team members are the heart of what makes us better. At Hackensack Meridian Health, we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.
The Clinical Documentation Specialist (CDS) facilitates improvement in the quality, completeness and accuracy of medical record documentation for the assigned hospital in the northern region of Hackensack Meridian Health. The CDS obtains and promotes appropriate clinical documentation through interaction with physicians, nursing staff, other patient caregivers, Health Information Management (HIM) coding staff, and Emergency Trauma Department (ETD), to ensure documentation reflects the level of service rendered is complete and accurate. The CDS educates all members of the patient care team on documentation guidelines on an ongoing basis. The CDS reviews ED inpatient admissions and observations as specified by the facility’s Utilization Management/Review Committee for documentation completeness and compliance with patient status, facilitates accurate documentation for severity of illness and medical necessity, and provides guidance for admission or observation disposition.
Responsibilities
Facilitate appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
Perform admission reviews for specific patient populations using clinical documentation guidelines.
Document appropriateness of patient admission, working DRG & LOS information on worksheet and computer system as appropriate.
Review physician and clinical documentation, lab results, diagnostic information and treatment plans and capture information on applicable documentation tools.
Identify documentation opportunities reflecting severity of illness, acuity and resource consumption; communicate with physicians to clarify opportunities.
Collaborate with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities.
Update DRG worksheets to reflect changes in patient status and procedures; finalize diagnoses with physicians.
Review medical records every 24-48 hours as appropriate and update documentation worksheets to reflect additional findings.
Communicate with physicians to ensure requests for documentation are noted and followed up; serve on multidisciplinary rounds as assigned.
Assist with follow-up reviews of clinical documentation, ensuring issues discussed are documented in the chart.
Document and analyze data; report instances of inappropriate patient care or discharge delays to the Director of Health Information.
Maintain ongoing education for new staff and participate in weekly educational conferences and performance improvement activities.
Collaborate with coding staff to determine appropriate DRG and required documentation; reconcile final coded DRG with the CDMP DRG at discharge.
Stay current with and educate others on the Clinical Documentation Management Program (CDMP) and related core measures and safety indicators.
Maintain positive communications with physicians and care teams; ensure documentation supports severity of illness and principal/secondary diagnoses.
Qualifications Education, Knowledge, Skills and Abilities Required
Graduation from medical school.
Minimum of 5 years of experience reviewing and screening inpatient admissions and observations or equivalent experience.
Experience improving medical records documentation quality and compliance.
Ability to interact well with physicians and allied health team members, including HIM coders.
Computer literate with working knowledge of Microsoft Word and Excel on Windows.
Excellent communication, organizational, analytical, writing and interpersonal skills.
Dependable, self-directed and pleasant; strong critical thinking, problem solving and deductive reasoning skills.
Recent hospital experience; knowledge of pathophysiology and disease processes.
Knowledge of Medicare Part A and Part B; regulatory environment; CDMP documentation strategies.
Understanding of POA/HAC and core measures; knowledge of admission appropriateness rules.
Education, Knowledge, Skills And Abilities Preferred
ICU/CCU and/or strong Medical/Surgical experience.
Licenses And Certifications
Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility.
Licenses And Certifications Preferred
CCDS or certification within two (2) years of eligibility.
Compensation and Benefits Starting at $47,777.60 Annually. Hackensack Meridian Health is committed to pay equity and transparency. The posted rate of pay is a reasonable good faith estimate of the minimum base pay for this role at the time of posting and does not reflect the full value of our total rewards package. Some jobs may be eligible for performance-based incentives, bonuses, or shift differentials.
HMH offers a comprehensive benefits package including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.
Equal Employment Opportunity Hackensack Meridian Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, genetic information, disability, marital status, veteran status, or other protected status.
Our Network: Hackensack Meridian Health is a mandatory influenza vaccination facility.
Apply and Connect If you are interested, please apply today.
#J-18808-Ljbffr