Clinical Documentation Specialist I Elevate Care

NYC Health + Hospitals; Hempfield Township (Westmoreland County); On-site; USD 90,000 - 125,000; Full time

Job summary

NYC Health + Hospitals seeks a Clinical Documentation Specialist to optimize documentation for severity of illness, mortality risk, and resource use. You will work with physicians and coding staff to ensure accurate, complete records and appropriate reimbursement.

Under supervision, you will review, report, process and assure quality of documentation, with opportunities for improvement and staff mentorship. This role may involve remote tasks as needed.

Qualifications

• Valid New York State license and current registration to practice as a Registered Nurse (RN) issued by NYSED; BSN degree; four years of acute care experience.
• Valid NYS license as Nurse Practitioner or Physician Assistant with required experience.
• Foreign Medical Graduate with two years of medical records review or utilization experience.
• Completion of education leading to a medical degree with two years of related experience.

Responsibilities

• Facilitates physician documentation for clinical conditions to support severity of illness and proper reimbursement.
• Performs concurrent and retrospective reviews of patient records for DRG assignment and Case Mix Index.
• Queries physicians to clarify documentation to ensure accurate coding and reimbursement.
• Educates providers on documentation and coding guidelines and compliance.
• Participates in LEAN/process improvement events and staff training.

Education

Registered Nurse (RN) license, NYS

Bachelor of Science in Nursing (BSN)

Nurse Practitioner (NP) license, NYS

Physician Assistant (PA) license, NYS

Foreign Medical Graduate

Medical degree with two years of related experience

Job description

NYC Health + Hospitals seeks a Clinical Documentation Specialist to optimize documentation for severity of illness, mortality risk, and resource use. You will work with physicians and coding staff to ensure accurate, complete records and appropriate reimbursement.

Under supervision, you will review, report, process and assure quality of documentation, with opportunities for improvement and staff mentorship. This role may involve remote tasks as needed.