New Jersey Licensed CDI Specialist

Job Summary

Focusing on the accuracy and completeness of inpatient clinical documentation, the full-time remote New Jersey Licensed CDI Specialist will perform concurrent chart reviews, collaborate with healthcare teams, and facilitate documentation modifications to ensure compliance with coding standards and improve data quality.

Key responsibilities

• Analyzes medical records to identify incomplete or inaccurate documentation related to diagnoses, treatments, and procedures
• Collaborates with healthcare providers to clarify and improve documentation while ensuring compliance with coding guidelines
• Conducts training sessions for healthcare staff on proper documentation practices and participates in quality improvement initiatives

Required qualifications

• Minimum of 3 years of experience in an inpatient clinical documentation improvement role
• Minimum of 5 years of nursing experience in adult acute care settings such as med/surg, critical care, emergency, or PACU
• Certification as CCDS and/or CDIP is required
• Current state Registered Nursing license is required
• Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems