Job Description

Our team members are the heart of what makes us better. At **Hackensack Meridian** **_Health_** we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. The **Clinical Documentation Specialist RN** facilitates improvement in the overall quality, completeness and accuracy of medical record documentation for assigned hospital/s of Hackensack Meridian Health (HMH). Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department (ETD), to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of the patient care team on documentation guidelines, on an on-going basis. Reviews and screens ED inpatient admissions and observations as specified by the facility's Utilization Management/Review Committee for documentation completeness and compliance with patient status. Facilitates accurate documentation for severity of illness and medical necessity. Interacts with physicians, case managers, and nursing staff and provides guidance and recommendations for admission or observation disposition. Assesses patients for present-on-admission (POA) conditions to ensure accurate documentation, regarding hospital acquired conditions (HAC). Communicates the transfer of appropriate concurrent information to the inpatient Case Managers and the Clinical Documentation Specialists (CDS), assigned to the unit. **Education, Knowledge, Skills and Abilities Required:** + Graduation from a bachelor's level program of Nursing (or in select cases, may allow to obtain within 2 years of hire). + Minimum of 5 or more years of recent clinical experience, preferably in Medical/Surgical Critical Care, Intensive Care or Emergency Room Care. + Ability to interact well with physicians and other members of allied health care team, including HIM coders. + Must be computer literate, have working knowledge and familiarity of Microsoft Word and Excel/Windows based software programs. + Must possess excellent communication, organizational, analytical, writing and interpersonal skills. + Dependable, self-directed and pleasant. + Critical thinking, problem solving and deductive reasoning skills. + Recent hospital experience. + Knowledge of Pathophysiology and Disease Process. + Knowledge of Medicare Part A. + Familiar with Medicare Part B. + Knowledge of regulatory environment. + Understand and support CDMP® documentation strategies. + Knowledge of POA/HAC and core measures. + Knowledge of Observation and Inpatient medical necessity. + Knowledge of regulatory requirements for appropriateness of admissions. **Education, Knowledge, Skills and Abilities Preferred:** + Advanced Practice Degree. + ICU, CCU and/or strong Medical/Surgical experience. **Licenses and Certifications Required:** + Current state Registered Nurse license. + Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility. If you feel that the above description speaks directly to your strengths and capabilities, then please apply today! 173214 Starting at $90,750.40 Annually HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package. The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to: + Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness. + Experience: Years of relevant work experience. + Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training. + Skills: Demonstrated proficiency in relevant skills and competencies. + Geographic Location: Cost of living and market rates for the specific location. + Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization. + Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered. Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts. In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits. HACKENSACK MERIDIAN HEALTH (HMH) IS AN EQUAL OPPORTUNITY EMPLOYER All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, refusal to submit to a genetic test or make available to an employer the results of a genetic test, atypical hereditary cellular or blood trait, national origin, nationality, ancestry, disability, marital status, liability for military service, or status as a protected veteran.

Job Tags

Hourly pay, Full time, Part time, Apprenticeship, Work experience placement, Shift work, Night shift, Weekend work, Afternoon shift,

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