Clinical Documentation Specialist

Mountainside Hospital Montclair , NJ 07042

Posted 4 weeks ago

  • Part Time/Day Shift

Who We Are

We are a patient-focused, community-oriented hospital that is conveniently located in Montclair that is equipped with technology that rivals the nation's most prestigious healthcare systems. Hackensack Meridian Health Mountainside Medical Center offers a comprehensive and growing array of services delivered by caring and highly-skilled medical professionals. We're proud of the therapeutic and administrative upgrades we have made. Mountainside Medical Center has been serving Montclair and its surrounding New Jersey communities since 1891. The physicians, nurses and volunteers who are a part of the Mountainside family are your friends and neighbors. We're your community, your hospital and team, who will continue to work hard for you.

Hackensack Meridian Health Mountainside Medical Center is proud to continue to provide world-class health care services in a community setting. Our 365-bed medical center has successfully transitioned from a stand-alone facility to being part of Hackensack Meridian Health, the most comprehensive and truly integrated network in New Jersey. Mountainside is a joint venture between Hackensack Meridian Health and Ardent Health Services, one of the country's leading private hospital management companies.

We are looking for a dynamic and passionate Clinical Documentation Specialist to join the Mountainside Team!

What You'll Do

The Clinical Documentation Improvement (CDI) Specialist works collaboratively with medical, nursing, and coding staff to ensure accurate capture of clinical information through chart review, querying, and education.

The successful candidate will be able to:

  • Facilitate concurrent modifications to clinical documentation supporting specificity of services and care provided

  • Educate all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies

  • Create job aids and queries in support of training initiatives

  • Ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting

  • Conduct follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart

  • Review clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding

  • Discuss cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings

  • Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured

  • Serve as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement efforts

  • Perform any and all other duties as assigned

What You'll Bring

  • Associate's Degree in Nursing required; Bachelor's 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

  • 1-2 years' experience as CDI Specialists preferred

  • 3M Coding and Reimbursement and/or 360 Encompass preferred

  • Working knowledge of ICD-10 preferred

What We Offer

  • Competitive pay

  • Medical, dental, and vision insurance

  • 401k with Company match

  • Company paid basic life insurance and long term disability coverage

  • Generous paid time off, including an additional extended illness bank

  • 6 Paid Holidays

  • Tuition Reimbursement

  • Advancement and career development opportunities

Hackensack Meridian Health Mountainside Medical Center is an Equal Opportunity Employer and applicants will receive consideration for employment regardless of race, color, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.


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Clinical Documentation Specialist

Mountainside Hospital