What are the responsibilities and job description for the Clinical Documentation Specialist - Ensuring Medical Record Accuracy position at RWJBarnabas Health Corporate Services?
Company Overview
RWJBarnabas Health Corporate Services seeks a skilled clinical documentation specialist to review patient medical records, ensuring accuracy and up-to-dateness with the latest information on a patient’s illness.
Job Summary
This role requires familiarity with medical codes indicating aspects of a patient's medical information, condition, and treatment.
Key Responsibilities
- Concurrently review and evaluate selected patient medical records for quality and completeness.
- Assist in clarifying documentation regarding diagnoses, procedures, co-morbid conditions, complications, and other reportable data elements.
- Collaborate with physicians, non-physician clinicians, and coding professionals on documentation opportunities, coding and reimbursement issues, and quality and performance improvement opportunities.
Required Skills and Qualifications
- Familiarity with ICD-10-CM coding requirements.
- Adult acute care experience in med/surg, critical care, emergency, or PACU.
- The ability to work independently with minimal supervision.
- Quick learning of new concepts and software.
Benefits Package
- Market-competitive salary.
- Comprehensive benefits package including medical and prescription drug insurance, dental and vision insurance, retirement plans, short and long-term disability, tuition reimbursement, and health care/dependent care flexible spending accounts.
