Clinical Documentation Specialist - Level II

NYC Health + Hospitals; Hempfield Township (Westmoreland County); Hybrid; USD 90,000 - 130,000; Full time

Job summary

NYC Health + Hospitals in Queens announces a Clinical Documentation Specialist role within the Health Information Management division. The incumbent ensures accurate documentation to reflect severity of illness, supports appropriate reimbursement, and coordinates with physicians, coding staff, and leadership to optimize patient care outcomes.

Responsibilities include chart reviews, physician queries, staff training, and participation in process improvements and regulatory compliance.

Qualifications

• Valid NYS license and current RN registration with BSN and four years of acute care experience.
• Valid NYS license and current NP registration with two years of experience.
• Valid NYS license and current PA registration with two years of experience.
• Foreign Medical Graduate with two years of medical records review or utilization experience.
• Completion of education leading to medical degree with two years of related experience.

Responsibilities

• Facilitates physician documentation to support appropriate illness severity and reimbursement.
• Obtains documentation through interaction with physicians and staff for accurate DRG/CMI.
• Performs concurrent and retrospective reviews for proper coding and risk assessment.
• Queries clinicians to clarify and resolve conflicting chart information.
• Provides feedback and follow-up to capture clarified documentation.
• Identifies weaknesses and collaborates with Finance to resolve issues.
• Analyzes data trends to identify improvement opportunities.
• Assists in preparing monitoring/trending reports for leadership.
• Leads orientation and mentoring of new staff members.
• Educates providers on documentation, coding guidelines, and reimbursement impact.
• Participates in meetings and LEAN process improvement activities.

Skills

Clinical documentation

Nursing

Medical record review

Communication

Education

Bachelor of Science in Nursing (BSN)

CCDS Certification

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.
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 general supervision, coordinates and supports the daily activities and services in an assigned department(s), unit(s) or area of service.

Examples Of Typical Tasks

At a more difficult and responsible level, performs the duties of Assignment Level I:

• 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.

Duties

In addition to performing the duties of Assignment Level I at a more difficult and responsible level, also performs the following:

• Contributes to the strategic planning and process improvement initiatives and activities related to clinical documentation, by providing expert-level review and assessment, and effective recommendations or solutions for improvement.
• Assists in the development of policies, procedures, and guidelines, or a review and/or revision of existing ones, to support best practices for clinical documentation program and staff and ensures all compliance and regulatory standards are met.
• Serves as lead Clinical Documentation Specialist, providing guidance to other Clinical Documentation Specialists and handles more difficult cases.
• Acts as a liaison and key resource for medical and other staff on interpretation and application of clinical documentation, ethical reporting and documentation standards and other related actions and matters. Actively monitors clinical documentation requests and responds to questions submitted and provides complete follow-through on all requests for clarification.
• Provides direction, training, and education to reporting and other assigned staff on performance of duties. Supervises accuracy and timeliness of work, work processes, and overall workload responsibilities.

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 casemanagement experience; or
• Successful completion of education that leads to a medical degree; and two (2) years of experience,as described in “4” above.

For Appointment To Assignment Level II

• Two (2) additional years of experience in Level I or two (2) additional years of experience performingthe tasks as identified above for Level I.
• Holds and maintains a Certified Clinical Documentation Specialist (CCDS) Certification issued by theAssociation of Clinical Documentation Improvement Specialists (ACDIS).

Department Preferences