Document Improvement Specialist (JR228801)

Montefiore New Rochelle; City of New Rochelle (NY); On-site; USD 75,000 - 90,000; Full time

Job summary

A leading healthcare documentation firm located in New Rochelle is seeking a Documentation Improvement Specialist. The role involves maintaining accuracy in medical documentation, conducting training, and participating in auditing processes. The ideal candidate will have a Bachelor's Degree in a healthcare field, excel in communication, and possess at least 3 years of leadership experience. Preferred certifications include CCS, CDIP, or RN. This position offers opportunities for professional growth and development in a rewarding environment.

Qualifications

• 3 years' leadership/supervisory experience required.
• Prior documentation improvement program experience is a plus.
• Excellent communication skills required.

Responsibilities

• Maintain professional standards in documentation.
• Conduct documentation audits and provide feedback.
• Participate in training and orientation of new staff.

Skills

Microsoft Excel

PowerPoint

3M system application

Outlook

Teaching skills

Presentation skills

Critical thinking

Education

Bachelor's Degree in a healthcare related field

Tools

Coding software

Job description

Overview

The Documentation Improvement Specialist maintains professional practice standards, clinical expertise, and demonstrates leadership skills. She/He participates in assigned projects designed to continually improve hospital performance targets at the medical center (e.g., auditing, service line education, etc.). She/he is responsible for validating the integrity of the medical record documentation in the overall completeness, accuracy, specificity and timeliness of documentation through extensive medical record and query process interrogation.

Conducts successful interventions related to documentation improvement and coding validation, and follows through with all software and supervisory recommendations based on their individual impact. Additionally, effective communication with appropriate clinical and coding staff, and utilization of all required computer programs and software is integral.

Identifies, investigates, evaluates practices and processes to facilitate continuous improvement in complete and accurate medical record documentation while maintaining records and databases to quantify the deficits. Maintains knowledge of regulatory requirements and policies regarding required documentation impact on coding, and DRG assignments AND CMS AND NEW YORK STATE HOSPITAL QUALITY PERFORMANCE DATA PROGRAMS. Monitors key indicator metrics associated with CDI, as they relate to revenue cycle and quality outcomes.

Responsibilities

• Completes concurrent and retrospective validation of system output (principal diagnosis, pertinent secondary diagnoses, post‑admission complications, Present on Admission Status (POA), Hospital Acquired Conditions (HACs), Patient Safety Indicators (PSIs), procedures, and electronic queries for accurate Diagnosis‑Related Group (DRG) assignment and Case Mix Index (CMI), risk of mortality, and severity of illness).
• Provides routine in‑services to assigned clinical areas/service lines regarding regulatory documentation requirements including feedback on the impact of clinician documentation on service specific metrics.
• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for performance improvement (i.e., trends responses to queries and completion, service line statistics, population‑specific query opportunities).
• Required consistent resource for clinical/service units; acts as a key support for physician and physician extenders on interpretation and application of documentation integrity, documentation standards, and other related actions and matters; provides complete follow‑through on all requests for clarification.
• Assists in the orientation and training of new staff members, and provides continual guidance and mentoring, as required.
• Integrates management/leadership skills into daily clinical/administrative practice.
• Collaborate with Health Information Management for review of denials based on clinical documentation queries and providing supporting documentation.
• Performs auditing functions on staff, including revalidation of assigned accounts, queries, and producing reports/tallies of quality of work (e.g., accuracy rates, educational opportunities, query per review rate).
• In manager's absence, assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians.
• Implements and substantiates CDIS software recommendations, therefore augmenting end user actions and productivity.
• Interfaces appropriately with software output for measurable outcomes and enhancement of the legal medical record.

Requirements

• Microsoft Excel, PowerPoint, 3M system application, Outlook.
• Prior experience in training peers and expertise in group presentations.
• Working knowledge of Medicare, and All Payer Refined, reimbursement systems and coding structures.
• Self‑motivated individual with cognitive thinking skills who is able to work independently with minimal supervision.
• Intellectual curiosity and desire to learn new skills.
• Knowledge of age‑specific needs and the elements of disease processes and related procedures.
• Prior documentation improvement program is a plus.
• 3 years' leadership/supervisoryexperience.
• Knowledge of coding concepts and related to coding or experience with hospital finance or hospital billing.
• Excellent verbal and written communication skills.
• Ability to work with providers, coders and other nurses, as well as the ability to problem solve and meet daily work productivity goals.
• Teaching and presentation skills are required.
• Excellent critical thinking skills are required.
• OHS Annual Assessment.
• Bachelor's Degree in a healthcare related field.
• CERTIFICATION IN CODING AND DOCUMENTATION INTEGRITY WITHIN THREE YEARS OF EMPLOYMENT IN THIS POSITION WITH ONGOING MAINTENANCE OF SUCH CERTIFICATION.
• 3 years' minimum of healthcare experience

Preferred Education and Certifications

• CCS, CDIP, RN, PA, NP, MD, CCDS, or trained Physician background or greater than 5 years' DRG experience.
• Master's Degree in a healthcare-related field.