OVERVIEW Joining Redeemer Health means becoming part of an inclusive, supportive team where your professional growth is valued. Our strength comes from bringing different perspectives and talent to our workforce, spanning PA & NJ. We offer programs that set up new team members for long-term success including education assistance, scholarships, and career training. With medical and dental coverage, access to childcare & fitness facilities on campus, investment in your retirement, and community events, your career at Redeemer is more than a job. You’ll discover a commitment to quality care in a safe environment and a foundation from which you can provide and receive personalized attention. We look forward to being a part of your professional journey. We invite you to apply today. SUMMARY OF JOB The Clinical Documentation Specialist (CDS) performs concurrent review of the medical record to promote the integrity of the clinical documentation, via analysis of clinical indicators and associated diagnostic terms that translate into ICD-10 /Working MS-DRG codes and reimbursable data to reflect the Severity of Illness (SOI), Risk of Mortality (ROM), and medical necessity that supports the level of care provided to all patients. The CDS facilitates the clarification of clinical documentation via an established physician query process and serves as an educator and consultant through interaction with providers, and other members of the healthcare team and coders with an overall objective to support the quality, completeness, accuracy and integrity of the medical record documentation. The CDS assist in the development and distribution of education. CONNECTING TO MISSION: All individuals, within the scope of their position, are responsible for performing their job in light of the Mission & Values of the Health System. Regardless of position, every job contributes to the challenge of providing health care. There is an ongoing responsibility for ensuring that the values of Respect, Compassion, Justice, Hospitality, Holistic Approach, Stewardship and Collaboration are present in all interactions with patients, residents, families and one another in the services we provide. RECRUITMENT REQUIREMENTS Three (3) years’ experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, Physician Assistant (PA), Nurse Practitioner (NP)/Advanced Practice nurse (APN), medical school graduate OR as an inpatient coder. Current experience utilizing encoding/grouping software or CAC is preferred. Ability to utilize both manual and automated versions of the ICD 10 coding classification systems is preferred Previous experience in inpatient coding or sufficient knowledge of clinical documentation, DRG assignment and clinical conditions and procedures. Excellent communication (verbal and written), interpersonal and relationship building skills necessary to maintain effective working relationships with employees, physicians, departmental directors, and Administration. Strong critical thinking skills and ability to incorporate clinical and coding knowledge to CDI setting. Strong organizational and prioritization skills. Effective presentation/facilitation and articulation skills to achieve educational goals for all member of the healthcare team. Computer proficiency including Word, PowerPoint and Excel. Ability to use standard desktop and Windows based computer system, including a basic understanding of email, internet, WebEx, Citrix and routine computer navigation. Ability to use other software applications (i.e. 3M 360 Encompass) and electronic medical record (EMR). Accurate data entry and typing skills at a minimum 30 words per minute. Comfortable operating independently and in a collaborative environment. LICENSE AND REGULATORY REQUIREMENTS: Must possess at minimum Associate/Diploma Degree in Nursing, OR Health Information Technology (HIT) OR/and Advanced degree in Health Information Management, nursing or medical field such as NP/APN or PA. Must possess one of the below: Current Registered Nurse License Registered Health Information Administrator (RHIA) Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS). Licensure as a Physician Assistant (PA) or Nurse Practitioner (NP)/ Advanced Practice Nurse (APN) or completion of medical school. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP). EQUAL OPPORTUNITY Redeemer Health is an equal opportunity employer. We prohibit discrimination in employment due to race, color, gender, religion, creed, national origin, age, sex, sexual orientation, gender identity or expression, disability veteran status or any other protected classification required by law.