Clinical Documentation Specialist

Albany Medical Center • Hudson, NY

11d

About The Position

Utilizes clinical expertise to assess clinical documentation concurrently and retrospectively; contributes to 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; exhibits extensive knowledge of clinical documentation requirements and DRG assignment; supports timely, accurate and complete documentation of clinical information used 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
• Valid Coding certification such as CCA or CCS preferred
• Current NYS RN license required for nurses
• If a foreign educated medical graduate, ECFMG certificate preferred
• 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 regarding 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 databases

Nice To Haves

• Valid CDI Certification such as CDIP or CCDS preferred
• CDI experience preferred

Responsibilities

• Utilizes clinical expertise to assess clinical documentation concurrently and retrospectively
• contributes to 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
• exhibits extensive knowledge of clinical documentation requirements and DRG assignment
• supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes

What This Job Offers

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