Clinical Document Specialist, Clinical Documentation Mgmt

Position Summary

The CDS facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff.

Active participation in team meetings and education of staff in the CDI process is a key role.

Major Roles

Job functions reflect the following objectives:

' Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using CDI documentation strategies

' Accurate and timely record review

' Recognize opportunities for documentation improvement

' Formulate clinically credible documentation clarifications

' Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety

' Effective and appropriate communication with physicians

' Timely follow up on all cases and resolution of those with clinical documentation clarifications

' Manage multiple priorities

Experience Required

' 5 years of adult acute care experience in med/surg, critical care, emergency, or PACU

Education/License/Certification

' Graduation from a program of nursing, BSN required.

' Current NJ state Registered Nurse license

RWJBarnabas Health is an