New Jersey Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation accuracy and support coding initiatives, the full-time New Jersey Licensed Clinical Documentation Specialist will perform concurrent chart reviews, analyze medical records for completeness, and collaborate with healthcare teams while working remotely.

Key responsibilities

• Analyze medical records to identify and rectify incomplete or inaccurate documentation related to patient diagnoses and treatments
• Facilitate clarification of clinical documentation through interactions with physicians and healthcare teams to ensure accurate representation of patient conditions
• Conduct training sessions for providers on documentation best practices and compliance requirements as directed by CDI leadership

Required qualifications

• BSN, PA, NP, or Doctorate degree in a medically related field required
• Minimum of 3 years of experience in a clinical documentation improvement role
• Active RN, MD, DO, NP, or PA license required
• Certification in CCDS and/or CDIP is mandatory
• Minimum of 5 years of nursing experience in adult acute care settings required