Documentation Specialist

Richmond Medical Center • Staten Island, NY

1d • $80,000 - $90,000 • Remote

About The Position

It's fun to work in a company where people truly BELIEVE in what they're doing! We're committed to bringing passion and customer focus to the business. Day Shift - 7.5 Hours (United States of America) The CDS facilitates accurate documentation for severity of illness (SOI) and quality in the medical record. This involves extensive record review, interaction The CDS facilitates accurate documentation for severity of illness (SOI) and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, coding professionals, and nursing staff. Active participation in team meetings and training of staff in the Nuance CDI process is a key role. Major Role: Review inpatient medical records for identified payer populations on admission and throughout hospitalization. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation. Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI). Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff. Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient’s clinical status and care. Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.

Requirements

• Organizational, analytical, and writing skills
• Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills
• Excellent time management
• Effective and appropriate communication with physicians & coding professionals
• Knowledge of regulatory guidelines
• Knowledge of Medicare Part A and MS-DRG and/or APR-DRG payment methodologies
• Ability to pass a written clinical competency assessment
• Basic computer skills
• A Bachelor of Science degree in Nursing or International Medical Graduate
• Must possess Minimum 5 years of acute care hospital experience
• Minimum 2 years of Inpatient Coding experience with ICD-10 CM/PCS.

Nice To Haves

• AHIMA CCA or CCS certification preferred
• ACDIS CCDS or AHIMA CDIP certification preferred
• CDI experience preferred

Responsibilities

• Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI).
• Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff.
• Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient’s clinical status and care.
• Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.

What This Job Offers

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