The Clinical Documentation Specialist facilitates updates to clinical documentation by collaborating with physicians and clinicians to accurately reflect severity, complications, and co-morbidities. Reviews and evaluates
patient records for quality and completeness. Educates physicians, nonphysician clinicians, and coding staff on documentation, coding, reimbursement, and quality improvement opportunities. Identifies documentation-related quality of care issues and resolves them appropriately.
Principal Accountabilities:
Review medical records to assign accurate DRG
Perform initial, concurrent, and retrospective reviews
Complete initial review within 24-48 hours of admission
Ensure SOI, ROM, and comorbidities are documented
Collaborate with coding staff for accurate documentation
Educate staff on documentation and coding guidelines
Train new C DS specialists, coders, physicians, residents
Share knowledge for ongoing team learning
Maintain compliance in chart reviews and queries
Support quality measures and system initiatives
At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:
We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group.
We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:
Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:
Team Member Benefits
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Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.
EEO STATEMENT
Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran
Required:
Associates Degree in Nursing;
Bachelor of Science Nursing degree preferred
5 years of Med/Surg acute care clinical experience required, experience in ICU strongly preferred
Registered licensed nurse (RN) required
Strong clinical knowledge in respiratory failure, sepsis, CHF, ATN/CKD, and complex pneumonias required
One-two years experience as CDI Specialists preferred
3M Coding and Reimbursement and/or 360 Encompass preferred
Working knowledge of ICD-10 preferred
Epic experience preferred
Preferred:
Ability to achieve cognitive, organizational and emotional maturity to deal effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers.
Possesses interpersonal/communication skills necessary for effective, non-judgmental, and empathetic patient care and customer relations.
Open to feedback and open to a changing environment, which requires flexibility in scheduling and department assignments.