New Jersey Licensed Clinical Documentation Specialist

Job Summary

To support clinical documentation efforts, the part-time New Jersey Licensed Clinical Documentation Specialist will ensure the quality and completeness of medical records while facilitating modifications through collaboration with healthcare teams in a remote setting.

Key responsibilities

• Ensure overall quality and completeness of medical records for all payor groups and DRGs
• Facilitate modifications to clinical documentation through concurrent interactions with physicians and nursing staff
• Educate the patient care team on documentation standards and practices as needed

Required qualifications

• Minimum of 5 years experience as a Clinical Documentation Specialist in an acute setting, preferably at a Level 1 Trauma Center
• CCDS or CDIP certification required
• Coding certification such as CCS, CRC, or CIC required
• International Medical Graduate (IMG) from an accredited medical school preferred
• Proficient in EPIC EHR and knowledge of risk adjustment coding (PSI/HAC/HCC)