Clinical Documentation Specialist

CentraState Healthcare System

Clinical Documentation Specialist responsible for reviewing patient medical records for proper coding and documentation improvement. Collaborating with healthcare professionals to ensure accuracy and adherence to standards.

Posted 5/27/2026full-timeRemote • New Jersey • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

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
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.

Benefits

Comp & perks

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical documentationcodingreimbursementICD-10clinical knowledgeMed/Surg acute carerespiratory failuresepsisCHFATN/CKD

Soft Skills

interpersonal skillscommunication skillsorganizational skillsemotional maturityflexibilitycustomer relationsability to handle stressability to manage multiple tasksnon-judgmental approachempathetic patient care

Certifications

Registered Nurse (RN)CCDSCDIP