Clin Doc Spec - P/T (20/hrs week)

Albany Medical Center • Albany, NY

2d • $77,075 - $119,466 • Hybrid

About The Position

This is a part-time position (20 hours per week) for a Clinical Documentation Specialist. The role utilizes clinical expertise to assess clinical documentation concurrently and retrospectively, aiming to improve the overall completeness and quality of the documentation and medical record. The specialist will collaborate extensively with physicians and other healthcare providers to ensure accurate reflection of patient complexity in the documentation. Responsibilities include providing ongoing education to healthcare providers on documentation importance, collaborating with HIM and Quality Management departments, and demonstrating extensive knowledge of clinical documentation requirements and DRG assignment. The role supports timely, accurate, and complete documentation for measuring and reporting physician and facility outcomes.

Requirements

• Bachelor’s degree in Nursing or health related degree is required.
• MD, DO, MBBS or foreign educated medical graduate with advanced clinical practice experience.
• Current NYS RN license required for nurses.
• Advanced clinical experience with extensive knowledge of complex disease processes and broad clinical practice experience in the inpatient and outpatient settings required.
• At least 5 years adult acute care practice experience.
• Demonstrated effective, collegial communication with physicians, other providers, staff and leadership through direct discussion and written communications.
• Excellent interpersonal and analytical skills.
• Must be able to function independently, interpret information, communicate with medical and clinical staff and both internal and external to the institution.
• Able to provide oral presentations both in person and virtually.
• Must be motivated, organized with excellent verbal, written communication skills, and conversant with adult professional learners.
• Ability to work independently and as a member of a team utilizing critical thinking skills.
• Demonstrated competence in data analysis and data interpretation.
• Knowledge of ICD-10 codes and coding guidelines.
• Ability to prioritize workflow and manage various initiatives.
• Demonstrated quality improvement knowledge/skills with regard to workflow and productivity processes.
• Strong speaking and writing skills required.
• Excellent presentation skills required.
• Able to produce reports in Microsoft Office components, Word, Power Point, Excel, and Access data bases.
• Demonstrated effective facilitation skills.
• Good listening skills.
• Strong interpersonal communication skills with the ability to relate to all levels of education and organization positions.

Nice To Haves

• CDI Certification such as CDIP or CCDS preferred.
• Coding certification such as CCA or CCS preferred.
• If foreign educated medical graduate, ECFMG certificate preferred.
• CDI experience preferred.

Responsibilities

• Utilizes clinical expertise to assess clinical documentation concurrently and retrospectively.
• Contributes to the improvement of the overall completeness and quality of the documentation/medical record.
• Collaborates extensively with physicians and other health care providers so that the clinical documentation reflects accurately the complexity of patient’s care.
• Provides ongoing education to all healthcare providers regarding the importance of accurate documentation.
• Collaborates with the HIM and the Quality Management departments.
• Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.

Benefits

• Excellent health care coverage with no copay at Albany Medical Center providers
• A wide array of services and programs to support emotional, physical, and mental wellbeing

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level