Clinical Documentation Specialist RN

About the role

The Clinical Documentation Specialist RN facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation for assigned hospitals in the northern region of Hackensack Meridian Health (HMH). This role involves extensive interaction with physicians, nursing staff, patient caregivers, Health Information Management Department coding staff, and the Emergency Trauma Department (ETD) to ensure clinical documentation reflects the level of service rendered. The specialist educates all members of the patient care team on documentation guidelines and reviews ED inpatient admissions and observations for completeness and compliance with patient status.

The CDS assesses patients for present-on-admission (POA) conditions, facilitates accurate documentation for severity of illness and medical necessity, and interacts with physicians, case managers, and nursing staff to guide admission or observation disposition.

Responsibilities

• Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
• Performs admission reviews for specific patient populations using clinical documentation guidelines.
• Assists in the medical screening process by documenting appropriateness of patient admission, working DRG & LOS information on worksheets and computer systems.
• Extensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans to capture appropriate information on CDMP® / 3M 360 worksheets.
• Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity, and resource consumption.
• Verbally communicates with physicians to clarify documentation opportunities and updates DRG worksheets to reflect changes in patient status.
• Reviews medical records every 24-48 hours and updates CDMP® / 3M 360 worksheets to reflect additional documentation, lab findings, and diagnostic results.
• Conducts follow-up reviews to ensure issues discussed with physicians are documented in the patient’s chart.
• Collaborates with coding staff to determine appropriate DRG and reconciles final coded DRG with CDMP® DRG assigned at discharge.
• Stays current with clinical documentation management programs and conducts ongoing education for new staff, physicians, and allied health professionals.
• Participates in concurrent performance improvement activities and reviews CDMP® / 3M 360 tracking data against established benchmarks.
• Screens ED inpatient admissions and observations to determine the necessity and appropriateness of hospitalizations using facility criteria.
• Recommends admission or observation disposition to ED physicians and collaborates with admitting physicians to place patients in the appropriate status.
• Attends and participates in Multidisciplinary Rounds (MDR) for assigned units.
• Reviews medical records for completeness and accuracy of severity of illness (SOI) using CDMP® documentation strategies.
• Assesses all appropriate admissions for POA documentation of conditions such as pressure ulcers, infections, DVT, pulmonary embolus, and risk for falls.
• Initiates core measure reviews for specific clinical topics (e.g., AMI, pneumonia, heart failure, stroke, sepsis) and follows CDMP® protocols for Patient Safety Indicators (PSIs).
• Provides ongoing education to ED and admitting physicians regarding appropriate documentation and criteria for admission, observation, and level of care.
• Maintains liaison with inpatient case managers and CDS to communicate necessary follow-up information.
• Performs other duties and projects as assigned.

Qualifications

• Education, Knowledge, Skills, and Abilities Required:
  • Graduation from a bachelor’s level program in Nursing (or in select cases, may allow obtaining within 2 years of hire).
  • Minimum of 5 or more years of recent clinical experience, preferably in Medical/Surgical Critical Care, Intensive Care, or Emergency Room Care.
  • Ability to interact well with physicians and other members of the allied healthcare team, including HIM coders.
  • Computer literacy with working knowledge of Microsoft Word, Excel, and Windows-based software programs.
  • Excellent communication, organizational, analytical, writing, and interpersonal skills.
  • Critical thinking, problem-solving, and deductive reasoning skills.
  • Recent hospital experience with knowledge of pathophysiology, disease processes, Medicare Part A/B, and regulatory environments.
  • Understanding and support of CDMP® documentation strategies, POA/HAC, core measures, and medical necessity for admissions.
• Education, Knowledge, Skills, and Abilities Preferred:
  • Advanced Practice Degree.
  • ICU, CCU, and/or strong Medical/Surgical experience.
• Licenses and Certifications Required:
  • Current state Registered Nurse license.
  • Certified Clinical Documentation Specialist (CCDS) or certification within two years of eligibility.

Pay

Minimum rate of $97,011.20 annually. The starting rate of pay is provided for informational purposes and may vary based on factors such as labor market data, experience, education, certifications, skills, geographic location, internal equity, and budget considerations. Some roles may also be eligible for performance-based incentives, bonuses, or shift differentials for evening, night, or weekend shifts.

Benefits

HMH offers a comprehensive benefits package for full-time and part-time (20+ hours/week) employees, including:

• Health, dental, and vision coverage.
• Paid leave.
• Tuition reimbursement.
• Retirement benefits.