Clinical Document Specialist - PD (On-Site)

About the Role

Holy Name is New Jersey's only independent Catholic health system, comprising a 361-bed acute care hospital, a renowned cancer center, a state-of-the-art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through graduate medical education, a Pharmacy Residency Program, and the Institute for Simulation Learning. The mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness.

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation. Responsible for analyzing clinical information for accurate representation of the severity of illness, this role involves extensive medical record review, interaction with physicians, HIM professionals, and nursing staff. The specialist works collaboratively with coding staff to assure documentation of discharge diagnoses and comorbidities completely reflects the patient's clinical status and care, and actively participates in team meetings for development and implementation of education for physicians, nurses, and ancillary staff on documentation improvement.

Responsibilities

• Learn and develop the skills necessary to perform CDMP®
• Conduct accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible documentation clarifications
• Effectively and appropriately communicate with physicians
• Perform timely follow-up on all cases, especially those with clinical documentation clarifications
• Participate in Task Force Meetings
• Manage multiple priorities
• Communicate with HIM staff and resolve discrepancies
• Accurately input data into CDMP Trak®
• Perform additional duties as assigned

Education

• Bachelor's Degree – Required
• Master's Degree – Preferred

Experience

• 4–6 years of clinical experience – Required

Skills & Abilities

• Organizational, analytical, writing, and interpersonal skills
• Basic computer skills
• Knowledge of Medicare Parts A & B, pathophysiology, disease process, and the regulatory environment

Licenses & Certifications

• RN – Registered Nurse – State Licensure and/or Compact State Licensure upon hire – Required

Benefits

Full-time and part-time employees have access to a comprehensive benefits package including low-cost medical coverage with generous employer contributions, dental and vision plans, discounted prescriptions, on-site child care, 401(k) matching, tuition reimbursement, paid time off, flexible spending accounts, legal and voluntary coverage options, life insurance, and free on-site parking. This is a per diem position; benefit eligibility may vary based on employment status.

Pay

Pay Range: $45.50 per hour. Final base compensation is determined based on employment status (Full/Part-Time or Per Diem), skills, education, experience, and internal equity considerations.

Schedule

Per Diem