Clinical Document Specialist - PD (On-Site)

Description Clinical Documentation Specialist (Per Diem)

Welcome to Holy Name, a medical center where innovation is not just a goal — it's a commitment. Here, medical excellence thrives, allowing hope to reign supreme and leaving no room for fear. At our hospital, every patient is cared for with undivided attention — because healing every soul is our sole focus.

Holy Name is New Jersey's only independent Catholic health system, comprising a 361-bed acute care hospital, a renowned cancer center, a state-of-the-art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through graduate medical education, a Pharmacy Residency Program, and our Institute for Simulation Learning. Our mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness. This is at the core of who we are and what we do, and we've done it this way across generations, every single day, for nearly 100 years. Every innovation, medical breakthrough, and groundbreaking treatment is powered by some of the best minds in medicine, ensuring nothing is left on the table or the road to recovery.

A Brief Overview The CDS facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Responsible for analyzing clinical information for accurate representation of the severity of illness. This involves extensive medical record review, interaction with physicians, HIM professionals and nursing staff. Must work collaboratively with coding staff to assure documentation of discharge diagnosis and co-morbidities are a complete reflection to the patient's clinical status and care. Active participation in team meetings for development and implementation of education for physicians, nurses and ancillary staff on documentation improvement. 

What You Will Do

• Able to learn/develop the skills necessary to perform CDMP®
• Conducts accurate and timely record review
• Recognizes opportunities for documentation improvement
• Formulates clinically credible documentation clarifications
• Effectively and appropriately communicates with physicians
• Performs timely follow up on all cases, especially those with clinical documentation clarifications
• Participates in Task Force Meetings
• Manages multiple priorities
• Communicates with HIM staff and resolves discrepancies
• Accurately inputs data into CDMP Trak®
• Performs additional duties as assigned

Education Qualifications

• Bachelor's Degree Required and
• Master's Degree Preferred

Experience Qualifications

• 4-6 years of clinical experience Required

Knowledge, Skills, And Abilities

• Organizational, analytical, writing, and interpersonal skills;
• Basic computer skills;
• Knowledge of Medicare Parts A & B, pathophysiology, disease process, and the regulatory environment

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required

At Holy Name, we believe in rewarding every team member with more than a paycheck—we invest in your future and well-being. Full-time and part-time employees have access to a comprehensive benefits package designed to support your health, financial security, and quality of life. We offer low-cost medical coverage with generous employer contributions, dental and vision plans, discounted prescriptions, and access to on-site child care. Additional benefits include 401(k) matching, tuition reimbursement, paid time off, flexible spending accounts, legal and voluntary coverage options, life insurance, and free on-site parking. If you are hired at Holy Name, your final base compensation will be determined based on factors such as employment status (Full/Part-Time or Per Diem) skills, education, and/or experience. In addition to those factors – we believe in the importance of pay equity and consider any internal equity of our current team members as a part of any final offer. Pay Range: $45.50

Holy Name is a mission-driven facility whose quality standards and philosophy are rooted in the principles of its founders, the Sisters of St. Joseph of Peace. Those principles are exercised daily by the Medical Center's dedicated and talented staff members. Holy Name is an Equal Opportunity Employer.