Clinical Documentation Specialist

BronxCare Health System • New York, NY

9d

About The Position

Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Knowledge of age-specific patient needs and the elements of disease processes and related procedures. Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

Requirements

• MD; MBBS or any equivalent degree, policy requirement.
• Bachelor's degree require.

Nice To Haves

• Current MD/MBBS CDI/Coding experience preferred, but not required

Responsibilities

• Provides concurrent and retrospective review of the clinical documentation in the medical record
• Review the medical record with a clinical lens to identify any missing or understated diagnoses.
• Review the chart for information not currently in the chart but that is indicated by clinical indicators in the record.
• Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan.
• Performs a thorough chart review to determine the appropriate principal diagnosis of the patient.
• Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.

What This Job Offers

• Job Type: Full-time
• Number of Employees: 1,001-5,000 employees