Documentation Improvement Specialist (CDI) - HYBRID (4 days in Queens office)
About The Position
The Documentation Improvement Specialist is responsible for facilitating improvement of medical record documentation by concurrent and retrospective interventions and interactions with, as well as the provision of education to physicians, residents, and other licensed independent practitioners. Develops process to identify opportunities for documentation improvement, intervene with attending physicians, residents, and physician extenders, in order to facilitate improvement in medical record documentation. Provides routine in-services to assigned clinical areas/Service Lines regarding regulatory documentation requirements including feedback on the impact of clinician documentation on Service Line metrics. Initiates and maintains records and databases to quantify the deficits, the interventions, and their impact. Conducts successful interventions related to documentation improvement and ensures follow through with all recommendations. Identifies, investigates, and evaluates practices and processes to facilitate continuous improvement in complete and accurate medical record documentation. Participates in retrospective medical record reviews to collect data and/or to resolve coding or documentation discrepancies. Maintains knowledge of coding, billing and documentation guidelines related to the therapists’ clinical professions and third party payer requirements. Collaborates with Manager of Coding Unit as needed. In collaboration with Coding Unit expertise, provides in-services to educate therapy staff and clinicians on the following but not limited to: correct billing, coding and documentation through clear verbal and/or written communication. Performs other job related duties as assigned. This is full time day (8:00 am - 4:00 pm) position. You will be expected to be in office 4-5 days a week.
Requirements
- Bachelor's degree
- Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant or trained Physician background
- 5 years of recent hospital experience and/or verifiable Documentation Improvement experience
- Experience in an Electronic Medical Record (EMR) environment
Nice To Haves
- Registered Nurse with 2 years of CDI experience
- Bachelor’s Degree in Nursing
- Current Registered Nurse, Nurse Practitioner or Physician Assistant license highly preferred
Responsibilities
- Facilitate improvement of medical record documentation by concurrent and retrospective interventions and interactions with, as well as the provision of education to physicians, residents, and other licensed independent practitioners.
- Develop process to identify opportunities for documentation improvement, intervene with attending physicians, residents, and physician extenders, in order to facilitate improvement in medical record documentation.
- Provide routine in-services to assigned clinical areas/Service Lines regarding regulatory documentation requirements including feedback on the impact of clinician documentation on Service Line metrics.
- Initiate and maintain records and databases to quantify the deficits, the interventions, and their impact.
- Conduct successful interventions related to documentation improvement and ensure follow through with all recommendations.
- Identify, investigate, and evaluate practices and processes to facilitate continuous improvement in complete and accurate medical record documentation.
- Participate in retrospective medical record reviews to collect data and/or to resolve coding or documentation discrepancies.
- Maintain knowledge of coding, billing and documentation guidelines related to the therapists’ clinical professions and third party payer requirements.
- Collaborate with Manager of Coding Unit as needed.
- In collaboration with Coding Unit expertise, provide in-services to educate therapy staff and clinicians on correct billing, coding and documentation through clear verbal and/or written communication.
- Perform other job related duties as assigned.
Benefits
- Comprehensive and competitive benefits that support you and your family in every aspect of life.
- Amazing compensation packages start with competitive base pay and include recognition for your experience, education, and licensure.
- Countless opportunities for personal and professional growth.
- A dynamic environment that embraces every person.
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
