Document Improvement Specialist, Fulltime

Stamford Health; Stamford (CT); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Competitive salary

Comprehensive health insurance

Paid Time Off accruals

Tuition reimbursement

Free on-site parking

Childcare partnership with Children’s Learning Center

Job summary

Stamford Health is looking for a full-time Document Improvement Specialist in Stamford, CT. This role involves facilitating process changes in clinical documentation to ensure compliance and accuracy. Candidates should have a CT Registered Nurse license, and experience with EPIC EMR and documentation improvement. The position offers competitive salary, health insurance from day one, and various benefits including tuition reimbursement and paid time off.

Qualifications

• A minimum of 5 years of experience in case management or coding.
• Prior training experience with competencies to develop education programs.
• High level of competency with computers and computer software.

Responsibilities

• Facilitate internal process changes to improve documentation.
• Conduct concurrent reviews of Medicare in-patient charts.
• Provide ongoing education to staff regarding coding guidelines.

Skills

EPIC EMR system experience

Data and statistical analysis using Microsoft Excel

Communication of written policies and procedures

Develop and present education programs

Compile objective and measurable data

Education

Connecticut Licensed Registered Nurse

Bachelor’s Degree in a related field

CCS, CCA, CPC‑H certification

Tools

MS Office

Data analysis software

Job description

Fulltime Document Improvement Specialist with our Case Management Team

Fulltime Monday through Friday 8am to 4pm with rotating weekends, located at our One Hospital Plaza, Stamford CT location.

At Stamford Health, we believe that every patient deserves compassionate, personalized, person‑centered care. This commitment guides how we care for patients, support their care partners, and promote the wellbeing of our staff. In alignment with our Planetree philosophy, the individual in this role will foster a respectful, collaborative environment that honors the needs, values, and preferences of every person we serve and the colleagues we partner with.

Responsibilities

This individual will facilitate internal process changes that bring together physicians, care managers and coders to address clinical documentation opportunities for improvement. Improve physician documentation compliance with criteria required under the Inpatient Prospective Payment System (IPPS), in order to eliminate payment errors on Medicare discharges caused by incomplete/inaccurate physician documentation; as well as ensure clear and concise documentation to meet the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and applicable federal and state law. Perform concurrent review of Medicare in‑patients charts to assess the physician documentation and its impact on the Diagnosis Related Group. Monitor the organization's potential financial risk and financial status of Medicare patients on a concurrent basis by reviewing records to ensure the documentation of the most accurate principal diagnosis and procedures and any pre‑existing conditions in adherence to Medicare definitions. Assist with compliance and abstraction of JCAHO Core Measures. The program is intended to provide concurrent documentation to accurately reflect the acuity of a patient's condition. This individual will work with senior management to make recommendation on overall strategy, work with case managers and coding staff to processes are in place for documentation capture and education of resident, physicians and extender staff on coding rules and strategies for documentation improvement.

• Develop in‑service programs with physicians, case management staff and coding manager regarding coding guidelines and the clinical documentation program.
• Provide ongoing education to case management staff, physicians and the interdisciplinary team regarding clinical documentation improvement program.
• Work with case managers, physicians and coders to establish appropriate documentation for correct coding.
• Track and trend the impact of efforts on overall CMI.
• Identify and prioritize DRG’s, physicians or cases for review concurrently for DRG optimization.

Qualifications

• Connecticut Licensed Registered Nurse.
• Bachelor’s Degree in a related field is preferred.
• CCS, CCA, CPC‑H certification preferred.
• MUST have EPIC EMR system experience.
• A minimum of 5 Years of experience in case management, managed care, coding and/or case mix – documentation improvement experience.
• The ability to compile objective and measurable data and produce written reports is required.
• The ability to develop and communicate written policies and procedures is required.
• Prior training experience and the competencies to develop and present education programs to all levels of healthcare professionals.
• High level of competency with computers and computer software such as MS Office or equivalent is required. Specifically, the ability to perform data and statistical analysis using Microsoft Excel or equivalent is required.
• Prior Hospital / Health Care experience is required.
• Experience in a Health Care System is highly preferred.

Benefits

• Competitive salary
• Comprehensive, low‑cost health insurance plans (including GLP‑1 coverage options) available day one
• Wellness programs
• Paid Time Off accruals
• Tax deferred annuity and (403b) pension plan
• Tuition reimbursement
• Free on‑site parking and train station shuttle
• Childcare partnership with Children’s Learning Center