Clinical Documentation Quality Champion II

Mount Sinai Medical Center; New York (NY); Hybrid; USD 80,000 - 109,000; Full time

Job summary

Mount Sinai Health System in New York seeks a Clinical Documentation Quality Improvement Specialist II to enhance the accuracy and completeness of patient records. This role works closely with physicians and care teams to capture complete documentation reflecting the level of service provided.

The position drives DRG classification accuracy, supports CDI data analysis, and collaborates with HIM/coding to ensure compliant, high-quality documentation while meeting productivity goals.

Qualifications

• 2 years of CCS, CDIP or CCDS certification or equivalent.
• Strong written and verbal communication abilities.
• Proficient in ICD-10 CM/PCS codes, DRG and CPT coding.
• Capable of concurrent auditing and physician query writing.

Responsibilities

• Facilitates improvement in the quality, completeness and accuracy of medical record documentation.
• Ensures accurate clinical documentation to support DRG classification.
• Analyzes patient status and history to identify documentation gaps.
• Writes concise physician queries to obtain necessary documentation.
• Reconciles cases with accurate recording of DRG/SOI impact.
• Identifies opportunities for improved documentation with peers.
• Understanding of complications, comorbidities and case mix impacts.
• Monitors compliance with payer regulations.
• Collaborates with HIM/coding to review problematic cases.
• Communicates with care team to document diagnoses/procedures accurately.
• Acts as consultant to coding staff when additional information is needed.
• Performs other related duties.

Skills

Interpersonal skills

Analytical skills

Problem solving

Attention to detail

Organization skills

Computer skills

ICD-10 CM/PCS, DRG & CPT knowledge

Education

CCS/CDIP/CCDS or equivalent

Job description

Mount Sinai Health System in New York seeks a Clinical Documentation Quality Improvement Specialist II to enhance the accuracy and completeness of patient records. This role works closely with physicians and care teams to capture complete documentation reflecting the level of service provided.

The position drives DRG classification accuracy, supports CDI data analysis, and collaborates with HIM/coding to ensure compliant, high-quality documentation while meeting productivity goals.