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Clinical Documentation Improvement Specialist - Hybrid Remote

White Plains Hospital -
White Plains, NY

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Job Details

Full-time
$95,373.14 - $143,059.00 a year

Qualifications

Computer operation
Inpatient experience
Medicare
Writing skills
Coding for hospital billing
Physiology knowledge
Windows
Medicare regulations
Desktop applications
Computer skills
Clinical documentation standards
DRG

Full Job Description

City/State:

White Plains, New York

Department:

WPH Health Info Mgmt HIM_1

Work Shift:

Day

Work Days:

MON-FRI

Scheduled Hours:

8 AM-4 PM

Hours Per Pay Period:

Pay Rate/Range:

$95,373.14 - $143,059

Job Summary

The CDIS facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Improvement Program (CDIP) process is a key role.

Essential Functions

1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors.
2. Reviews the medical record for completeness and accuracy for severity of illness (SOI) and quality using the current CDI software and electronic medical record.
3. Performs accurate and timely initial and concurrent record review
4. Recognize opportunities for documentation improvement
5. Facilitates appropriate clinical documentation to support accurate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
6. Formulate clinically credible documentation clarifications (queries) to improve clinical documentation and capture of the appropriate principal diagnosis and all comorbidities.
7. Request documentation clarifications as appropriate for principal diagnosis, severity of illness, risk of mortality, risk adjustment and quality measures.
8. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation.
9. Timely follow up on all cases and resolution of those with clinical documentation clarifications.
10. Collaborate with HIM coding staff to promote complete and accurate clinical documentation and resolve discrepancies and appropriate DRG assignment.
11. Communicates with coders and resolves discrepancies
12. Conducts post discharge reviews and reconciliation of queries.

Qualifications

BSN Required or
BS
4-6 years 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU. Required
Score (minimum of 70%) on the Clinical Competency Assessment (CCA)
Organizational, analytical, writing and interpersonal skills
Dependable, self-directed and pleasant
Critical thinking, problem solving and deductive reasoning skills
Knowledge of Pathophysiology and Disease Process
Basic Computer skills – familiarity with Windows based software programs
Knowledge of disease processes in all clinical specialties, anatomy & physiology and pharmacology and must have the ability to correlate abnormal lab results to disease processes
Knowledge of official coding guidelines and documentation requirements related to the Inpatient Prospective Payment System
Knowledge of regulatory environment
Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments
Knowledge of Coding Guidelines & Quality Measures
Registered Nurse New York - New York State Board of Nursing If RN, RN NYS License Upon Hire Required or
Physician Assistant - New York State Board of Medicine If PA, PA NYS license Upon Hire Required

White Plains Hospital Medical Center is an equal employment opportunity employer. White Plains Hospital Medical Center will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.

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