Atlantic Health

Clinical Documentation Specialist

Atlantic Health  •  New Jersey (Onsite)  •  5 hours ago
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Job Description

Responsible for reviewing patient medical records throughout hospitalization to capture accurate representation of the severity of illness and facilitate proper coding. Validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.

Principal Accountabilities:

  • Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
  • Creates job aids and queries in support of training initiatives
  • Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting
  • Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart
  • Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding
  • Discusses 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
  • Serves 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
  • Performs other relevant duties as assigned

  • Bachelor of Science Nursing degree preferred
  • Associates Degree in Nursing minimum required
  • 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
  • CCDS or CDIP [referred

    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.

#LI-AW1

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:

  • Atlantic Health Morristown Medical Center, Morristown, NJ
  • Atlantic Health Overlook Medical Center, Summit, NJ
  • Atlantic Health Newton Medical Center, Newton, NJ
  • Atlantic Health Chilton Medical Center, Pompton Plains, NJ
  • Atlantic Health Hackettstown Medical Center, Hackettstown, NJ
  • Atlantic Health Goryeb Children's Hospital, Morristown, NJ
  • Atlantic Health CentraState Healthcare System, Freehold, NJ
  • Atlantic Medical Group
  • Atlantic Visiting Nurse
  • Atlantic Mobile Health
  • Atlantic Rehabilitation

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:

  • Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For."
  • Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026.
  • Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings.
  • Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm.
  • Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026.
  • Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026.
  • Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026.
  • Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025.
  • Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired.

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

  • Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
  • Life & AD&D Insurance.
  • Short-Term and Long-Term Disability (with options to supplement)
  • 403(b) Retirement Plan: Employer match, additional non-elective contribution
  • PTO & Paid Sick Leave
  • Tuition Assistance, Advancement & Academic Advising
  • Parental, Adoption, Surrogacy Leave
  • Backup and On-Site Childcare
  • Well-Being Rewards
  • Employee Assistance Program (EAP)
  • Fertility Benefits, Healthy Pregnancy Program
  • Flexible Spending & Commuter Accounts
  • Pet, Home & Auto, Identity Theft and Legal Insurance

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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


Atlantic Health

About Atlantic Health

Atlantic Health is at the forefront of medicine, setting standards for quality health care in New Jersey, Pennsylvania and the New York metropolitan area. Headquartered in Morristown, NJ, we are a leading non-profit health care system, powered by a passionate workforce of 24,000 team members dedicated to building healthier communities. Atlantic Health serves more than half the state of New Jersey, including 14 counties and 7.5 million people and provides care for the full continuum of health needs across a wide array of settings, including dozens of outpatient and urgent care locations, Atlantic Rehabilitation Institute, Atlantic Health Goryeb Children’s Hospital, Atlantic Visiting Nurse and Atlantic Mobile Health. Our acute care hospitals include:

• Atlantic Health Morristown Medical Center, Morristown, NJ

• Atlantic Health Overlook Medical Center, Summit, NJ

• Atlantic Health Newton Medical Center, Newton, NJ

• Atlantic Health Chilton Medical Center, Pompton Plains, NJ

• Atlantic Health Hackettstown Medical Center, Hackettstown, NJ

• Atlantic Health CentraState Medical Center, Freehold, NJ

We receive awards and recognitions for our extraordinary care and our supportive workplace culture. Below are just a few of our accolades:

• 100 Best Companies to Work For® - Great Place to Work® and FORTUNE® magazine for 16 years

• One of the 100 Best Workplaces for Millennials: Great Place to Work® and FORTUNE® magazine

• America’s Greatest Workplaces in Health Care: Newsweek

• America’s Greatest Workplace for Women, Gen Z and Inclusion and Diversity: Newsweek

• Best Places to Work in Healthcare – Modern Healthcare

• 150 Top Places to work in Healthcare – Becker’s Healthcare

• Best Employers for Workers over 50 – AARP

• Gold-Level "Well Workplace": Wellness Council of America (WELCOA)

• System for Change Award from Practice Greenhealth

Industry
Healthcare & Social Services
Company Size
5,001-10,000 employees
Headquarters
Morristown, New Jersey
Year Founded
Unknown
Website
atlantichealth.org
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