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RN Clinical Documentation Specialist

Job Title
RN Clinical Documentation Specialist
Job ID
Highland Park,  NJ
Other Location

Looking for a career change from being a Critical Care RN. We have an excellent opportunity where you can use your Expertise being a Critical Care RN.  Our client is looking for a Clinical Documentation Specialist (CDS) to facilitate improvement in the overall quality, completeness and accuracy of medical record documentation.

· The individual will perform concurrent inpatient medical record reviews.

· Interact with physicians, Health Information Services (HIS) coding staff and other members of the health care team to ensure the accuracy and completeness of clinical documentation supports resource utilization, length of stay and patient outcomes.

· On an ongoing basis, educates all members of the patient care team and participates in the development of educational tools and programs for the health care team.

· The individual will collect and analyze data to determine the effectiveness and efficiency of clinical documentation processes and physician participation.

· This position reports to the Program Manager, Clinical Documentation. 

Required Skill Sets 

· Minimum five (5) years of progressive clinical experience in an acute inpatient care setting and /or critical care experience critical care.
· Self-directed individual with diverse clinical knowledge and highly developed problem solving and critical thinking skills.
· Previous experience in medical record chart review, working knowledge of DRG methodology and knowledge of ICD-10 CM coding classification system preferred.
· Ability to communicate effectively with physicians and other clinical professional staff.
· Previous CDI program experience a plus. 
· Bachelor´s level degree in nursing required
· Demonstrated proficiency with computer systems and database software
· Registered Nurse, AHIMA, C.C.S. and/or C.C.D.S. certification a plus.

Highly competitive salary and great benefits with Joining Bonus. 


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