Clinical Documentation Quality Improvement Specialist II-Mount Sinai Brooklyn - Full-time - Day
About The Position
The Clinical Documentation Quality Improvement Specialist II is responsible for improving the overall quality and completeness of clinical documentation. This role facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that documentation reflects the complete and accurate level of service rendered to patients. The position requires an experienced CDQI Specialist with a minimum of 2-4 years of recent experience in a CDI role. Performance expectations include meeting quality and quantity targets within 6 months of employment, with a quality review target of ≥ 93% and a quantity target of 10-14 initial chart reviews per day, with more than 5 agree queries per work day. The specialist is also expected to attain Clinical Documentation Specialist certification through ACDIS or AHIMA. Additionally, the CDI Specialist II assists leadership in utilizing expertise in CDI and data analysis to evaluate CDI accuracy, standardize review findings, and report results. The role demands effective and efficient work, the ability to manage multiple tasks simultaneously while maintaining productivity and quality outcomes.
Requirements
- 2 years of CCS, CDIP or CCDS or equivalent
- Good written, oral and interpersonal skills
- Excellent problem solving and analytical skills
- Strong organization skills
- Attention to details
- Strong computer skills
- Demonstrated knowledge of ICD-10 CM/PCS codes, DRG and CPT coding
Nice To Haves
- Experienced CDQI with minimum 2-4 years recent experience in CDI role
- Attains Clinical Documentation Specialist certification through ACDIS or AHIMA
- Works effectively and efficiently, able to work on several things at once while maintaining expected productivity outcomes.
- Meets established productivity goals without sacrificing quality.
Responsibilities
- Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records.
- Facilitates accurate clinical documentation to ensure appropriate DRG classification is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer.
- Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.
- Ability to write queries that are concise and easily understood by the queried provider, in order to garner additional necessary documentation in the inpatient medical record.
- Timely reconciliation of all cases, to include accurate recording of DRG or SOI impact based on physician query, as well as physician response to all queries.
- Identify query opportunities, diagnoses not supported by clinical indicators, and function on par with other CDI team members.
- Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team.
- Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations.
- Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisor.
- Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.
- Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data and clinical validation.
- Performs other related duties.
Benefits
- Salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
