Clinical Document Specialist
Company: RWJBarnabas Health Corporate Services
Location: Jersey City
Posted on: April 5, 2026
|
|
|
Job Description:
Job Title: Clinical Document Specialist Location: Barnabas
Health Corp Department: Clinical Documentation Mgmt Req: 0000175122
Status: Full-Time Shift: Day Pay Range: $91,472.00 - $129,204.00
Annual Pay Transparency: The above reflects the anticipated annual
salary range for this position if hired to work in New Jersey. The
compensation offered to the candidate selected for the position
will depend on several factors, including the candidate's
educational background, skills and professional experience. Job
Overview: A clinical documentation specialist (CDS) reviews a
patient’s medical records to ensure documentation is accurate as
well as up-to-date with the latest information on a patient’s
illness. They also record the details of every step-in clinical
treatment. A CDS must have familiarity with the codes involved with
medical records, each of which is used to indicate some aspect of
the patient’s medical information, condition and the treatment
received. A CDS must have the clinical knowledge to talk with
doctors, nurses and other healthcare providers about the treatment
a patient has received, especially if there are gaps in the
healthcare record. Qualifications: Required: Graduate from an
accredited school of nursing with a BSN degree Minimum 5 years
acute hospital experience as a clinical nurse Must read, write and
speak English. Passing grade on Clinical Competency Exam Advanced
understanding of anatomy, physiology, pathophysiology, and
pharmacology Excellent interpersonal, oral and written
communication and organizational skills Must maintain a
professional demeanor Must display a proven analytical capability
The ability to work independently with minimal supervision Able to
quickly learn new concepts and software Preferred: CCDS
certification (preferred) Prior experience in clinical
documentation review Understanding of ICD-10-CM coding requirements
Experience in a supervisory role Adult acute care experience in
med/surg, critical care, emergency, or PACU Certifications and
Licenses Require: Current New Jersey Licensed Registered Nurse
Scheduling Requirements: Working Hours: Hybrid - four days onsite,
one day remote. Subject to change based on business needs. Physical
Working Location: Jersey City Medical Center in Jersey City, NJ
Essential Job Functions Concurrently review and evaluate selected
patient's medical records for overall quality and completeness
Assisting in clarifying documentation regarding the patient’s
diagnoses and/or procedures, co-morbid conditions, complications,
and other reportable data elements including quality measures and
severity of illness and risk of mortality (SOI/ROM) Clarifications
will be completed by utilizing computer software to generate the
clarification. Collaborate with physicians, non-physician
clinicians, coding professionals on an ongoing basis regarding
documentation opportunities, coding and reimbursement issues and
relevant quality and performance improvement opportunities. Other
Duties: Please note this job description is not designed to cover
or contain a comprehensive listing of activities, duties or
responsibilities that are required of the employee for this job.
Duties, responsibilities and activities may change at any time with
or without notice. At RWJBarnabas Health, our market-competitive
Total Rewards package provides comprehensive benefits and resources
to support our employees’ physical, emotional, social, and
financial health. Paid Time Off (PTO) Medical and Prescription Drug
Insurance Dental and Vision Insurance Retirement Plans Short & Long
Term Disability Life & Accidental Death Insurance Tuition
Reimbursement Health Care/Dependent Care Flexible Spending Accounts
Wellness Programs Voluntary Benefits (e.g., Pet Insurance)
Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon,
and more! Choosing RWJBarnabas Health! RWJBarnabas Health is the
premier health care destination providing patient-centered,
high-quality academic medicine in a compassionate and equitable
manner, while delivering a best-in-class work experience to every
member of the team. We honor and appreciate the privilege of
creating and sustaining healthier communities, one person and one
community at a time. As the leading academic health system in New
Jersey, we advance innovative strategies in high-quality patient
care, education, and research to address both the clinical and
social determinants of health. RWJBarnabas Health aims to truly
make a unique impact in local communities throughout New Jersey.
From vastly improving the health of local residents to creating
educational and career opportunities, this combination greatly
benefits the state. We understand the growing and evolving needs of
residents in New Jersey—whether that be enhancing the coordination
for treating complex health conditions or improving community
health through local programs and education. Equal Opportunity
Employer LI-AB1
Keywords: RWJBarnabas Health Corporate Services, Greenwich , Clinical Document Specialist, Healthcare , Jersey City, Connecticut
