Job Description

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical records documentation. Reviews and recommends opportunities for documentation improvement through extensive record review. Obtains appropriate clinical documentation through extensive interaction with physicians, patient care providers and the coding team to ensure the clinical documentation reflects the level of service rendered to the patient is complete and accurate. Educates members of the patient care team regarding documentation guidelines on an ongoing basis. Demonstrates knowledge and skills necessary to assign an accurate severity of illness.

Work requires the knowledge of theories, principles and concepts normally acquired through completion of a Bachelor's degree in Nursing, Masters degree preferred, and three to five years of previous work related experience in Medical/Surgical, Intensive Care, Emergency Department, or PACU. Medical school graduate (MD, MBBS) or Registered Nurse (RN) and Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Integrity Specialists or Certified Documentation Integrity Practitioner (CDIP) or Certified Coding Specialist (CCS) by the American Health Information Management Association within two years or hire.

St. Joseph’s Health is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization’s outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation’s “100 Best Places to Work in Health Care”.

Benefits Eligibility: (Full-time and Part-time Employees-over 20 hours a week)

• Competitive salary*
• Robust benefits with health, dental, Rx and vision plans
• 403b retirement plan options with company match**
• Health & Wellness*
• Non-Profit Health System – eligible for Federal Student Loan Forgiveness
• PTO, and paid holidays
• Tuition reimbursement
• Employee Assistance Program
• LTD : Long Term Disability
• Life Insurance Options
• Onsite Day care Program

*Available for Per Diem Employees and Part-time Employees working under 20 hours per week.

**403b Company Match not applicable for Per Diem Employees and Part-time Employees working under 20 hours per week.

Pay transparency: St. Joseph’s Health provides a salary range to comply with New Jersey Law. The rate of pay for each position will be determined based on a variety of factors including the candidate's relevant experience, qualifications, skills, etc.” The salary range does not include incentives, differential pay or other forms of compensation.