Clinical Documentation Specialist

1 week ago


Egg Harbor City, New Jersey, United States AtlantiCare Full time
Job Summary

We are seeking a highly skilled Registered Nurse to join our team as a Clinical Documentation Integrity (CDI) RN. This role is responsible for improving the quality and completeness of clinical documentation to accurately reflect the provider intensity of service, patient severity of illness, and overall risk of mortality.

Key Responsibilities
  • Initiate concurrent and/or retrospective clinical medical record reviews for hospital patients
  • Monitor and perform systematic review to determine compliance to established documentation standards and billing/coding/reporting/query guidelines
  • Conduct follow-up reviews as necessary
  • Apply established practices and concepts to perform professional work
  • Proficiency in the use of CDI and coding systems, CDI/coding concepts, and data analysis
Requirements
  • Graduate of an accredited school of nursing required
  • Bachelor's in Nursing required
  • Current licensure as a Registered Nurse in the State of New Jersey/Nursing Compact state required
  • 5 years relevant clinical experience required
  • 3 years recent hands-on experience as inpatient Clinical Documentation Integrity (CDI) RN required
Working Environment

This position requires frequent walking and standing. Potential for exposure to the hazards and risk of the hospital environment, blood borne pathogens, including exposure to infectious disease, hazardous substances, and potential injury.

Reporting Relationship

This position reports to Department Leadership and may supervise incumbents as assigned.



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