Document Improvement Specialist

2010 Montefiore New Rochelle Hospital; City of New Rochelle (NY); On-site; USD 75,000 - 95,000; Full time

Job summary

Montefiore New Rochelle Hospital is seeking a Documentation Improvement Specialist to ensure the completeness and accuracy of medical records. This role involves conducting validation of system outputs, providing training, and analyzing data for performance improvements.

The ideal candidate will have leadership experience and a Bachelor’s degree in a healthcare-related field. Proficiency in Microsoft tools and knowledge of coding concepts are essential. Join us in enhancing hospital performance!

Qualifications

• Minimum of 3 years healthcare experience with leadership experience.
• Knowledge of coding concepts, hospital finance, and DRG experience required.
• Proficiency in Microsoft Office applications essential.

Responsibilities

• Conduct validation of system outputs for accurate DRG assignment.
• Provide in-services to clinical areas on documentation requirements.
• Analyze statistical data for performance improvement opportunities.
• Assist in training and orientation of staff.

Skills

Leadership skills

Strong communication skills

Analytical skills

Teaching and presentation skills

Critical thinking

Self-motivated

Education

Bachelor’s degree in a healthcare-related field

Master’s degree (preferred)

Certification in Coding and Documentation Integrity

Tools

Microsoft Excel

PowerPoint

3M system application

Outlook

Job description

Job Summary

The Documentation Improvement Specialist maintains professional practice standards and demonstrates leadership skills while participating in projects designed to improve hospital performance targets. This role validates the integrity of medical record documentation, ensuring completeness, accuracy, specificity, and timeliness, and conducts interventions related to documentation improvement and coding validation.

Responsibilities

• Conduct concurrent and retrospective validation of system outputs, including principal diagnosis, secondary diagnoses, post‑admission complications, POA status, HACs, PSIs, procedures, and electronic queries for accurate DRG assignment and CMI, risk of mortality, and severity of illness.
• Provide routine in‑services to clinical areas/service lines on regulatory documentation requirements and feedback on the impact of clinician documentation on metrics.
• Analyze and trend statistical data for specified patient populations to identify opportunities for performance improvement.
• Serve as a key resource for clinical/service units, supporting physicians and physician extenders in documentation standards and related actions.
• Assist with orientation and training of new staff, providing guidance and mentoring.
• Collaborate with Health Information Management to review denials based on clinical documentation queries and provide supporting documentation.
• Perform auditing functions on staff, including revalidation of accounts, queries, and producing reports on quality of work.
• Assist in preparation and presentation of clinical documentation monitoring/trending reports to physicians in the manager’s absence.
• Implement and substantiate CDIS software recommendations to enhance end‑user productivity.

Qualifications

• Bachelor’s degree in a healthcare‑related field; Master’s preferred.
• Minimum of 3 years healthcare experience, including 3 years leadership/supervisory experience.
• Knowledge of coding concepts, hospital finance or billing, and DRG experience.
• Experience with Medicare and all‑payer reimbursement systems.
• Proficiency in Microsoft Excel, PowerPoint, 3M system application, and Outlook.
• Strong verbal and written communication skills.
• Teaching and presentation skills required.
• Excellent critical thinking and problem‑solving skills.
• Self‑motivated, capable of working independently with minimal supervision.
• Prior experience in training peers and group presentations is a plus.

Required Education & Certifications

• Certification in Coding and Documentation Integrity within three years of employment, with ongoing maintenance of such certification.
• Preferred certifications: CCS, CDIP, RN, PA, NP, MD, CCDS, or trained physician background with more than 5 years DRG experience.

Montefiore New Rochelle Hospital is an equal employment opportunity employer.