Clinical Documentation Specialist
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AI Summary
The Clinical Documentation Specialist facilitates updates to clinical documentation by collaborating with physicians and clinicians to accurately reflect severity, complications, and co-morbidities. Reviews and evaluates
patient records for quality and completeness. Educates physicians, nonphysician clinicians, and coding staff on documentation, coding, reimbursement, and quality improvement opportunities. Identifies documentation-related quality of care issues and resolves them appropriately.
Principal Accountabilities:
1. Review medical records to assign accurate DRG
2. Perform initial, concurrent, and retrospective reviews
3. Complete initial review within 24–48 hours of admission
4. Ensure SOI, ROM, and comorbidities are documented
5. Collaborate with coding staff for accurate documentation
6. Educate staff on documentation and coding guidelines
7. Train new C DS specialists, coders, physicians, residents
8. Share knowledge for ongoing team learning
9. Maintain compliance in chart reviews and queries
10. Support quality measures and system initiatives
At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:
- Atlantic Health Morristown Medical Center, Morristown, NJ
- Atlantic Health Overlook Medical Center, Summit, NJ
- Atlantic Health Newton Medical Center, Newton, NJ
- Atlantic Health Chilton Medical Center, Pompton Plains, NJ
- Atlantic Health Hackettstown Medical Center, Hackettstown, NJ
- Atlantic Health Goryeb Children's Hospital, Morristown, NJ
- Atlantic Health CentraState Healthcare System, Freehold, NJ
- Atlantic Medical Group
- Atlantic Visiting Nurse
- Atlantic Mobile Health
- Atlantic Rehabilitation
We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group.
We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:
- Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For."
- Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026.
- Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings.
- Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm.
- Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026.
- Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026.
- Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026.
- Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025.
- Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired.
Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:
Team Member Benefits
- Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
- Life & AD&D Insurance.
- Short-Term and Long-Term Disability (with options to supplement)
- 403(b) Retirement Plan: Employer match, additional non-elective contribution
- PTO & Paid Sick Leave
- Tuition Assistance, Advancement & Academic Advising
- Parental, Adoption, Surrogacy Leave
- Backup and On-Site Childcare
- Well-Being Rewards
- Employee Assistance Program (EAP)
- Fertility Benefits, Healthy Pregnancy Program
- Flexible Spending & Commuter Accounts
- Pet, Home & Auto, Identity Theft and Legal Insurance
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Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.
EEO STATEMENT
Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran
Atlantic Health System is at the forefront of medicine, setting standards for quality health care powered by a workforce of more than 18,000 team members and 4,800 affiliated physicians dedicated to building healthier communities, the system offers more than 400 sites of care, including eight award-winning medical centers. Specializing in cardiovascular care, cancer care, orthopedics, neuroscience, pediatrics, women's health and rehabilitation medicine. Atlantic Medical Group, comprised of 1,000 physicians and advanced practice providers, represents one of the largest multi-specialty practices in New Jersey and includes finance, legal, marketing, human resources, talent acquisition, ISS and more. Caring for our patients, our team members and the communities we serve is our central mission.
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