Clinical Documentation Specialist

Position Summary

The Clinical Documentation Specialist (CDS) plays a key role in supporting patient access to timely care by managing prior authorizations for medications, imaging, laboratory testing—and specialist referrals. The CDS will also be managing the Maternal Fetal Medicine buckets to ensure efficiency and follow ups. The CDS also supports the medical clearance workflow, ensuring all necessary clinical documentation and evaluations are completed to clear patients for procedures and specialist care. This role requires close collaboration with providers, care teams, and insurance companies to minimize delays and optimize patient outcomes.

Responsibilities

• Submits prior authorizations for prescription medications, diagnostic imaging, specialty laboratory work, specialist referrals and procedures.

• Ensure authorizations meet payer-specific medical necessity requirements.
• Track and follow up on pending authorization requests.
• Document all authorization activity in the electronic health record (EHR).
• Manage and addresses maternal-fetal medicine buckets in a timely manner
• Work closely with providers to ensure timely submission and completion of orders.
• Communicate with patients regarding MFM-related testing and authorizations as needed.
• Assist in coordinating pre-operative or specialty procedure clearances.
• Review patient charts to identify outstanding labs, imaging, or consultations.
• Ensure all clearance requirements are met prior to scheduled services.
• Serve as a liaison between providers, patients, and specialists to facilitate medical clearance.
• Communicate professionally with insurance carriers, pharmacy benefit managers, and external specialists.
• Work collaboratively with clinical staff, care coordinators, and administrative teams.
• Educate patients and families on the authorization and clearance process when appropriate.
• Maintain accurate and up-to-date records in the EHR.
• Ensure all actions are compliant with HIPAA and confidentiality regulations.
• Stay current on payer-specific authorization guidelines and workflow policies
• Adheres to Corporate Compliance policies.

• Maintains a passing monthly scorecard threshold at 80%.
• Other duties as assigned.

Education/Experience/Licensure

• Active State of New Jersey LPN license or CMA Certification is preferred.
• One to three years experience in a medical center or community health care settings is required.
• Minimum of one to two years of clinical or care coordination experience is required.
• Minimum of two years of prior authorization experience, including medication prior authorizations is required.
• Certified Basic Life Support through American Heart Association is preferred.
• Bilingual English/Spanish is preferred.
• Proficiency in Microsoft Office 365 is required.
• Flexibility to meet the hours of the practice including evenings and weekends is required.
• Flexibility to cover shifts at other current and future OHI sites is required.
• Must have your own reliable transportation throughout Ocean and Monmouth Counties as required by OHI.

Benefits:

• Paid Time Off (PTO)
• Holidays (9)
• Health Insurance
• Dental Benefits
• 401(k) match
• Group Term Life Insurance
• Flexible Spending Account

Pre-Employment Requirements:

• Physical
• Criminal Background Checks
• Drug Screening
• Tuberculosis Screening