Clinical Documentation Specialist I - Remote

Mount Sinai Morningside; New York (NY); On-site; USD 66,000 - 99,000; Full time

Job summary

Mount Sinai Health System's Mount Sinai Morningside seeks a Clinical Documentation Specialist to improve outpatient documentation and coding quality across physician practices.

You will review ambulatory records, conduct coding audits with emphasis on HCC, educate physicians, and coordinate with Health Information Management and the CDQI leadership team to ensure accurate capture of patient status and care delivered.

Qualifications

• Minimum 3 years coding experience.
• At least 1 year of HCC Risk Adjustment experience preferred.
• Clinical background in healthcare setting preferred.
• Credentials CCS/CRC/CPC required.

Responsibilities

• Improve quality, completeness and accuracy of medical record documentation and coding.
• Review charts for outpatient encounters and primary care visits.
• Conduct coding and clinical validation audits focusing on HCC.
• Educate physicians and staff on compliant documentation and accurate coding.
• Collaborate with Health Information Management and physicians.
• Monitor coding changes from governmental agencies.

Skills

Coding experience

HCC Risk Adjustment

Clinical documentation

Excel

Communication skills

Education

High school diploma or GED; Associates or greater preferred

CCS (Certified Coding Specialist)

CRC (Certified Risk Adjustment Coder)

CPC (Certified Professional Coder)

Tools

Job description

Description

Job Description

MSHP seeks a Clinical Documentation Specialist who will support efforts to improve the overall quality and completeness of clinical documentation and coding in outpatient physician practices. They will work closely with physicians, Health Information Management and the Mount Sinai Health Partners team to review and code ambulatory medical records, identify opportunities to improve coding, educate physicians, and act as a liaison between all parties.

Responsibilities

• Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation and coding.
• Reviews charts to assess the clinical status of patients, current treatment plan, and past medical history to identify potential gaps in clinical documentation related to outpatient encounters, with a particular focus on primary care visits.
• Performs on-site or electronic coding and clinical validation audits and interpretation of medical documentation to ensure capture of all relevant coding. A particular focus with be on Hierarchical Condition Categories (HCC) coding, which is used by CMS and other payers to determine illness complexity and estimate patient risk of future health care utilization.
• Leverages data provided by available information technology (such as billing data) to identify additional opportunities to improve the comprehensiveness and specificity of outpatient coding
• Communicates and coordinates chart reviews with physician office staff and distributes correspondence related to review.
• Analyzes returned CDQI alerts for accuracy and completeness
• Reviews outpatient visit diagnoses and service levels prior to claim submission to ensure they accurately reflect the clinical status of patients and the type of care delivered
• Proactively solicits clarification from physicians to ensure key aspects of care have been appropriately recorded in the patient’s chart
• Participates in data acquisition, development of performance reports and communication of results to physicians, practice managers, and the CDQI leadership team
• Interacts regularly with physicians, particularly primary care providers, in the outpatient setting, providing ongoing education regarding compliant documentation and accurate coding, and serves as clinical liaison to the coding department
• Identifies training needs, prepares summary reports and conducts coaching as appropriate for clinicians and other staff to improve the quality of the documentation to accurately reflect members’ health status.
• Monitors coding changes by governmental agencies and other payers; educates practices on coding and compliance issues
• Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations
• Performs other related duties.

Qualifications

Education And Experience

• High school diploma or general education degree (GED); Associates or greater preferred
• Must have a minimum of 3 years coding experience
• At least 1 year of HCC Risk Adjustment experience, preferred
• Clinical background in a healthcare setting, preferred
• Credentials in one or more of the following, required:
• Certified Coding Specialist (CCS)
• Certified Risk Adjustment Coder (CRC)
• Certified Professional Coder (CPC)

Additional Skills And Qualities

• Demonstrated experience with front-end process improvement initiatives
• Thorough knowledge of ICD-10, CPT, and HCPCS
• Familiarity and understanding of CMS HCC Risk Adjustment coding and data validation requirements
• Familiarity with APC coding
• Experience with Microsoft Excel and Strong communication and mentoring skills
• Ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization
• Strong time management skills
• Excellent organization skills
• Must possess high degree of accuracy, efficiency and dependability
• Excellent written and oral communication for representation of clear and concise results

Employer Description

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About The Mount Sinai Health System

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children’s Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.

Compensation

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $65885 - $98827 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.