RWJBarnabas Health · 1 day ago
Clinical Document Specialist
Oceanport, NJ
Full-time
Hybrid
Mid, Senior Level
$91K/yr - $129K/yr
5+ years expRWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine. The Clinical Document Specialist reviews patient medical records to ensure accuracy and completeness, collaborating with healthcare providers to address documentation gaps and improve clinical records.
DiabetesHealth CareNeuroscienceOutpatient CareRehabilitation
Responsibilities
Concurrently review and evaluate selected patient's medical records for overall quality and completeness
Assisting in clarifying documentation regarding the patient’s diagnoses and/or procedures, co-morbid conditions, complications, and other reportable data elements including quality measures and severity of illness and risk of mortality (SOI/ROM)
Clarifications will be completed by utilizing computer software to generate the clarification
Collaborate with physicians, non-physician clinicians, coding professionals on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities
Qualification
Required
Graduate from an accredited school of nursing with a BSN degree
Minimum 5 years acute hospital experience as a clinical nurse
Must read, write and speak English
Passing grade on Clinical Competency Exam
Advanced understanding of anatomy, physiology, pathophysiology, and pharmacology
Excellent interpersonal, oral and written communication and organizational skills
Must maintain a professional demeanor
Must display a proven analytical capability
The ability to work independently with minimal supervision
Able to quickly learn new concepts and software
Current New Jersey Licensed Registered Nurse
Preferred
CCDS certification (preferred)
Prior experience in clinical documentation review
Understanding of ICD-10-CM coding requirements
Experience in a supervisory role
Adult acute care experience in med/surg, critical care, emergency, or PACU
Benefits
Paid Time Off (PTO)
Medical and Prescription Drug Insurance
Dental and Vision Insurance
Retirement Plans
Short & Long Term Disability
Life & Accidental Death Insurance
Tuition Reimbursement
Health Care/Dependent Care Flexible Spending Accounts
Wellness Programs
Voluntary Benefits (e.g., Pet Insurance)
Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!
Company
RWJBarnabas Health
RWJBarnabas Health is New Jersey’s largest and most comprehensive academic health system, caring for more than 5 million people annually.
10001+ employees
Funding
Current Stage
Late StageTotal Funding
$0.23MKey Investors
New Jersey Food Security Initiative
2024-07-02Grant· $0.23M
Leadership Team
Anthony Cava
President and CEO
Jordan Ruch
Chief Technology Officer
Recent News
2025-04-29
2025-04-14
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