Clinical Documentation Specialist

Iselin, New Jersey 08830


  • Full time
  • $$85,000/per year

Job Description

~The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness.  This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff.   Active participation in team meetings and education of staff in the CDMP® process is a key role.
The Primary Function of the CDS                                         

Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA) and quality core measures, patient safety indicators (PSI)
Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses and ancillary staff.
Work collaboratively with the coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
Develop and implement plans for education of physician, nursing and ancillary staff on documentation improvement.
Compensation Package:

An excellent, team focused work environment with opportunity for professional growth

Competitive salary and savings plan with company match

A variety of health, dental and vision plans

On-site child care, tuition reimbursement, and much more!

Job Requirements
Registered Nurse with BSN/MSN,
Minimum of 5 years in clinical practice
Critical care or strong medical / surgical background
Certified CCDS/CDIP and/or CCS with 3M360-DRG Assurance experience preferred

About Mitchell Martin Healthcare LLC

~~Mitchell Martin Healthcare is a national clinical staffing company providing exceptional talent in all disciplines of Allied Health and Nursing. As a company dedicated to delivering the highest standards in compliance, we are recognized and certified by The Joint Commission
30+ years providing Clinical Staffing nationwide on Per Diem, Staffing and Direct Hire basis
Loyal client base who have relied on our services since inception
Requested by Joint Commission to replicate our model for standards of quality compliance
Privately held $200M company managed by the founder
Executive management team with exceptionally long tenure

Innovative and Unique Recruiting Methodology
Tenured recruiting team experienced in hiring all lines of Nursing and Allied Health Professionals
Proprietary Database healthcare candidates and dedicated onshore/offshore recruiting
Source best in class talent from social media, associations, and referral network
Proprietary tool to source candidates nationwide increases efficiency for sourcing
In depth interview process to ensure delivery of the best candidate for each opportunity

Company Info

Clinical Documentation Specialist


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