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The Clinical Documentation Specialist will facilitate modifications to clinical documentation, through concurrent interactions with physicians and other clinicians to reflect appropriate clinical severity, complications and co-morbidity. The specialist shall concurrently review and evaluate selected patient’s medical records for overall quality and completeness. Will educate physicians, non-physician clinicians, coding professionals on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities. Will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels.

Principal Accountabilities:

1. 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

2. Creates job aids and queries in support of training initiatives

3. Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting

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

5. Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding

6. Discusses cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings

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

8. 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

9. Performs other relevant duties as assigned

Required:

1. Associates Degree in Nursing;

2. Bachelor of Science Nursing degree preferred

3. 5 years of Med/Surg acute care clinical experience required, experience in ICU strongly preferred

4. Registered licensed nurse (RN) required

5. Strong clinical knowledge in respiratory failure, sepsis, CHF, ATN/CKD, and complex pneumonias required

6. One-two years experience as CDI Specialists preferred

7. 3M Coding and Reimbursement and/or 360 Encompass preferred

8. Working knowledge of ICD-10 preferred

9. Epic experience preferred

Preferred:

1. Ability to achieve cognitive, organizational and emotional maturity to deal effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers.

2. Possesses interpersonal/communication skills necessary for effective, non-judgmental, and empathetic patient care and customer relations.

3. Open to feedback and open to a changing environment, which requires flexibility in scheduling and department assignments.

At Atlantic Health System, 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 20,000 team members. Headquartered 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:

+ Morristown Medical Center, Morristown, NJ

+ Overlook Medical Center, Summit, NJ

+ Newton Medical Center, Newton, NJ

+ Chilton Medical Center, Pompton Plains, NJ

+ Hackettstown Medical Center, Hackettstown, NJ

+ Goryeb Children's Hospital, Morristown, NJ

+ CentraState Healthcare System, Freehold, NJ

+ Atlantic Home Care and Hospice

+ Atlantic Mobile Health

+ Atlantic Rehabilitation

We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.

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:

+ 100 Best Companies to Work For ® and FORTUNE® magazine for 15 years

+ Best Places to Work in Healthcare - Modern Healthcare

+ 150 Top Places to work in Healthcare - Becker's Healthcare

+ 100 Accountable Care Organizations to Know - Becker's Hospital Review

+ Best Employers for Workers over 50 - AARP

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

+ One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine

+ One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine

+ Official Health Care Partner of the New York Jets

+ NJ Sustainable Business

Atlantic Health System 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 System, 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 status.