Clinical Documentation Specialist Level I

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

Marketing Statement

Queens Hospital Center is making good on its promise to the people of southeastern and central Queens to maximize both patient convenience and positive clinical outcomes. Residents of Queens can count on the delivery of quality medical care right in their own borough. In 2002 the hospital opened a state-of-the-art, 261-bed facility that includes the Queens Cancer Center, the first comprehensive cancer treatment center in the borough.

Marketing Statement

Queens Hospital Center is making good on its promise to the people of southeastern and central Queens to maximize both patient convenience and positive clinical outcomes. Residents of Queens can count on the delivery of quality medical care right in their own borough. In 2002 the hospital opened a state-of-the-art, 261-bed facility that includes the Queens Cancer Center, the first comprehensive cancer treatment center in the borough.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Duties & Responsibilities

Purpose of Position: Under the direction of the Director of Clinical Documentation, Director of Health Information Management or a designee for revenue management and recovery, facilitates and obtains appropriate physician documentation for clinical conditions or procedures to support the appropriate severity of Illness, expected risk of mortality, and complexity of patient care and to optimize reimbursement, ensuring patient centered quality care, optimal utilization of resources, service delivery and compliance with NYC Health + Hospitals, hospital, and all relevant regulatory policies, procedures, and standards of care for better outcomes and improved patient experience. Demonstrates effective communication, planning, and organizational skills and keeps current knowledge in the clinical documentation field and of all applicable regulations. All personnel perform related work and may perform tasks remotely, as authorized.

Under supervision, performs assigned duties related to reviewing, reporting, processing and quality assurance of clinical documentation.

Examples Of Typical Tasks

• Facilitates improvement in the overall quality, completeness, accuracy, specificity and timeliness of physician clinical record documentation through extensive medical record review, query process, and effective communication with appropriate clinical and coding staff, and by utilizing computer programs and systems.
• Obtains appropriate physician documentation for clinical conditions or procedures through extensive on-going interaction with physicians, other patient caregivers, and medical records coding staff to ensure the clinical documentation properly captures information describing patients’ acuity, severity of illness, and risk of mortality. Reflects the level of service delivered to patients is appropriate, complete, and accurate and supports appropriate reimbursement for the level of service rendered to all patients.
• Completes concurrent and retrospective reviews of patient records for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, postadmission complications and procedures for accurate Diagnosis-Related Group (DRG) assignment and Case Mix Index (CMI), risk of mortality, and severity of illness.
• Queries physicians for incomplete, inconsistent, unclear or conflicting health record documentation to clarify and resolve conflicting information in patient’s medical record prior to patient’s discharge; maintains a record of review and query activities and other appropriate records.
• Provides feedback and completes follow-up review of patient medical record, to ensure points of clarification have been addressed and recorded in the patient’s chart, and to assign a working/updated or final DRG upon patient discharge and before final coding and quality reporting submissions, as necessary.
• Identifies and reports areas of weakness that may impact financial opportunities, and works with Finance or other appropriate staff in resolution of problems.
• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
• Assists in the orientation and training of new staff members, and provides continual guidance and mentoring, as required.
• Educates providers on proper clinical documentation and coding guidelines and practices, and compliance and reimbursement issues on an ongoing basis. Advises on the impact of provider documentation on accurate reporting of a patient’s clinical information and reimbursement.
• Attends and/or participates in staff, departmental and interdisciplinary meetings, LEAN efficiency/ process improvement events, training and quality assurance/performance improvement (QA/PI) activities.
• Performs other related work, as assigned.

Minimum Qualifications

• Valid New York State license and current registration to practice as a Registered Professional Nurse(RN) issued by the New York State Education Department (NYSED); and Bachelor of Science inNursing degree from an accredited college or university; and four (4) years of acute care experience;or
• Valid New York State license and current registration to practice as a Nurse Practitioner (NP) issuedby the NYSED; and two (2) years of experience, as described in “1” above; or
• Valid New York State license and current registration to practice as a Physician Assistant (PA)issued by the NYSED; and two (2) years of experience, as described in “1” above; or
• Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience; or
• Successful completion of education that leads to a medical degree; and two (2) years of experience,as described in “4” above.