Documentation Improvement Specialist (CDI) - HYBRID (4 days in Queens office)
About The Position
The Documentation Improvement Specialist facilitates improvements in medical record documentation through concurrent and retrospective interventions and education for physicians, residents, and other licensed independent practitioners. The role develops processes to identify documentation-improvement opportunities and works with attending physicians, residents, and physician extenders to improve medical record documentation. It provides routine in-services to assigned clinical areas and Service Lines on regulatory documentation requirements, including feedback on how clinician documentation affects Service Line metrics. The specialist maintains records and databases tracking documentation deficits, interventions, and their impact; conducts interventions and ensures recommendations are followed through; and evaluates practices and processes for continuous improvement in complete and accurate documentation. The specialist also participates in retrospective medical record reviews to collect data and resolve coding or documentation discrepancies. The role maintains knowledge of coding, billing, and documentation guidelines relevant to therapists’ clinical professions and third-party payer requirements, collaborating with the Manager of Coding Unit as needed. In collaboration with Coding Unit experts, the specialist educates therapy staff and clinicians on correct billing, coding, and documentation through clear verbal and written communication, and performs other related duties as assigned. This is a full-time day position, 8:00 a.m. to 4:00 p.m., with an expectation of working in the office four to five days per week. The role requires on-site presence, and employees should live within commuting distance of NewYork-Presbyterian; travel expenses are not reimbursed.
Requirements
- Bachelor’s degree.
- Background as a Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant, or trained Physician.
- Five 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 two years of CDI experience.
- Bachelor’s degree in Nursing.
- Current Registered Nurse, Nurse Practitioner, or Physician Assistant license is highly preferred.
Responsibilities
- Facilitate improvements in medical record documentation through concurrent and retrospective interventions and interactions, and by educating physicians, residents, and other licensed independent practitioners.
- Develop processes to identify documentation-improvement opportunities and intervene with attending physicians, residents, and physician extenders.
- Provide routine in-services to assigned clinical areas and Service Lines on regulatory documentation requirements, including feedback on the impact of clinician documentation on Service Line metrics.
- Maintain records and databases to quantify documentation deficits, interventions, and their impact.
- Conduct documentation-improvement interventions and ensure follow-through on recommendations.
- Identify, investigate, and evaluate practices and processes to support continuous improvement in complete and accurate medical record documentation.
- Participate in retrospective medical record reviews to collect data and resolve coding or documentation discrepancies.
- Maintain knowledge of coding, billing, and documentation guidelines related to therapists’ clinical professions and third-party payer requirements.
- Collaborate with the Manager of Coding Unit as needed.
- Collaborate with Coding Unit experts to provide in-services for therapy staff and clinicians on correct billing, coding, and documentation.
- Perform other job-related duties as assigned.
Benefits
- Comprehensive and competitive benefits supporting employees and their families.
- Opportunities for personal and professional growth.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
