Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care, and two urgent care offices. Non-acute care is offered through various affiliates, including the Thompson House for rehabilitation and skilled nursing services, and the Home Care organizations.
The Clinical Documentation and Data Integrity Specialist will work with the Senior and Lead Specialist to ensure the overall improvement of the quality and completeness of Medical Record Documentation. Responsible for documentation accuracy, completeness and consistency in medical record from daily chart review. Ensures appropriate concurrent DRG assignment, documentation of severity of illness and risk of mortality from medical record review. Learn to collaborate with physician and other front line clinical staff under the guidance of senior/lead specialist with dotted line report to system manager. Reviews expected case volume both new and recurrent form daily work list. Ensures that daily target goal of cases reviewed is achieved and the work assignment is complete. Work with senior/lead CDDIS to optimize productivity goals. Review and validate POA status for Hospital Acquired Complication with providers when needed and correspond with quality team. Identify and review Patient Safety and Adverse Event, PSI complication for clinical validation using AHRQ provide inclusion exclusion criteria. This position requires full-time onsite presence.
1. Reviews inpatient medical records for identified payer population as directed on admission and throughout hospitalization. Analyze clinical status of patient, current treatment plan and past medical history and capture accurate SOI, ROM data
2. Identifies issues requiring clarification or additional information in the clinical documentation and initiates communication with the appropriate physician or other care provider through compliant query practice
3. Works with CDDI lead to maintains an open and collaborative working relationship with the patient care team, physician champions, and care coordination, denial management, quality and HIM coding staff
4. Participates in CDI team meetings to discuss difficult cases, questions and performance improvement strategies
5. Accurately identifies and reports outliers to Lead CDI and or Manager of CDI program
6. Maintains working knowledge of official ICD-10 and documentation guidelines
7. Assists in resolving inconsistent, conflicting and/or ambiguous documentation through compliant query practice
8. Ensures the query verbiage is in no way leading or suggestive in tone and is supported by the documentation in the record to include clinical indications and treatment provided.
Any one of these credential is acceptable:
RN (BSN or MSN), PRN, MD (local or International medical graduate), PA and or RHIA
One of the following certification upon hiring, CDIP, CCDS or acquire within 6 months of hiring
Experience working in inpatient setting for 3 years, 5 years is a plus
Experience with clinical documentation integrity and reportable quality data measures (PSI, HAC)
Have worked in large health system with multiple acute care hospitals
Norwalk-34 Maple St
8:00am - 4:30pm
Clincial Document Improvement
- Some manual skills / motor coord & finger dexterity
- Sedentary/light effort. May exert up to 10 lbs. force
- Some exposure to dirt, odors, noise, human waste, etc.
- Some occupational risk
Nuvance Health and its affiliates are Section 501(c)(3) tax-exempt organizations and therefore eligible employees may qualify for forgiveness of certain federal student loans under the Public Service Loan Forgiveness Program.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Qualified Applicants are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other classification protected under applicable Federal, State or Local law.
We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-739-7330 (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.