Clinical Document Specialist

Clinical Document Specialist – Full‑time day shift at Clara Maass Medical Center, Belleville, NJ – Revenue Cycle and Patient Access. Salary: $113,390–$147,407 per year (New Jersey). Job Overview A Clinical Document Specialist reviews patient medical records to ensure documentation is accurate and up‑to‑date. The role records all clinical treatment steps, applies medical coding knowledge, and collaborates with physicians, nurses, and coding professionals to address documentation gaps and improve coding and reimbursement outcomes. Essential Job Functions Review and evaluate selected patients’ medical records for overall quality and completeness. Clarify documentation regarding diagnoses, procedures, comorbid conditions, complications, and other reportable data elements, including quality measures and severity of illness/risk of mortality (SOI/ROM). Complete clarifications using computer software to generate the needed documentation. Collaborate with physicians, non‑physician clinicians, and coding professionals on documentation, coding, reimbursement, and quality improvement opportunities. Required Qualifications Graduate from an accredited nursing school 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, written communication, and organizational skills. Maintain a professional demeanor. Demonstrate proven analytical capability. Work independently with minimal supervision. Quickly learn new concepts and software. Preferred Qualifications CCDS certification. 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 & Licenses Current New Jersey Licensed Registered Nurse. Scheduling Requirements Hybrid schedule – four days onsite, one day remote (subject to change based on business needs). Physical location: Clara Maass Medical Center in Belleville, NJ. Benefits 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 partners such as NJ Devils, NJ PAC, Verizon, and more! 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. Equal Opportunity Employer Statement RWJBarnabas Health is an Equal Opportunity Employer. #J-18808-Ljbffr RWJBarnabas Health