Clinical Documentation Specialist (Located in Manhattan) (Hybrid position)

NYU Langone Health is a world-class, patient-centered, integrated academic medical center, known for its excellence in clinical care, research, and education. It comprises more than 200 locations throughout the New York area, including five inpatient locations, a children’s hospital, three emergency rooms and a level 1 trauma center. Also part of NYU Langone Health is the Laura and Isaac Perlmutter Cancer Center, a National Cancer Institute designated comprehensive cancer center, and NYU Grossman School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. At NYU Langone Health, equity, diversity, and inclusion are fundamental values. We strive to be a place where our exceptionally talented faculty, staff, and students of all identities can thrive. We embrace diversity, inclusion, and individual skills, ideas, and knowledge. For more information, go to nyulangone.org, and interact with us on LinkedIn, Glassdoor, Indeed, Facebook, Twitter, YouTube and Instagram.

Position Summary:
We have an exciting opportunity to join our team as a Clinical Documentation Specialist.

In this role, the successful candidate is responsible for the facilitation of improvement in the overall quality completeness and accuracy of medical record documentation by thorough chart review and extensive interaction with physicians nurses other patient care providers and HIM coding staff

Job Responsibilities:

• Assists with special projects as needed and perform related duties as assigned.
• Uses software and CDI tools to conduct concurrent review to evaluate documentation adequacy
• Performs admission/continued stay review on assigned charts to include assignment of DRG, based on coding guidelines/regulations (i.e. AHA Coding Clinic, CMS, AHIMA), identification of complications and/or co-morbid conditions, and specific co-existing conditions.
• Applies knowledge of DRG documentation requirements to accomplish appropriate coding and to reflect accurate case mix index and clinical outcomes for the hospital.
• Queries physicians for clarification and specificity of documentation in accordance with hospital policies and the AHIMA practice brief (Managing an Effective Query Process).
• Interprets clinical information in the medical record (i.e. medications, vital signs, surgical outcomes, laboratory/diagnostic test results) to identify potential diagnoses.
• Consults a physician advisor when indicated by review results and/or query response
• Maintains worksheets on all concurrent reviews
• Logs all concurrent queries.
• Re-reviews medical records at discharge to identify responses to queries and validate documentation adequacy.
• Confers with coding staff and HIM leadership to review assignment of appropriate DRG and completeness of supporting documentation as needed.
• Reviews documentation for core measure standards and confers with the health care team to facilitate appropriateness of documentation.
• Facilitates continuity of patient care by assisting in the screening process, making referrals and interacting with physicians and case management staff.
• Provides post discharge/pre-bill retrospective review of records in HIM for potential documentation improvement by applying concurrent standards of review and query processes.
• Coordinate final reporting of diagnoses with coding staff, providing clinical recommendations as needed.
• Identifies opportunities for physician/practitioner education to improve documentation for severity of illness.
• Participates in educational training programs regarding appropriate documentation required for complete and accurate coding and reporting.
• Serves as a resource to staff and physicians to obtain information or clarification on accurate and ethical reporting and documentation standards, guidelines and regulatory requirements
• Implements and participates in corrective action plans to ensure resolution of problem areas which are identified during internal or external auditing.
• Provides feedback to physicians and other staff on the results of auditing and monitoring activities

Minimum Qualifications:
RN, Coder, or Healthcare Professional.
Bachelor’s degree required (for all hires after 2008).
Five years recent experience in adult medical/surgical acute care, utilization review, case management, or clinical documentation improvement.
NY State Licensed RN or PA.
CCDS preferred.

OR

Coder:
Bachelor’s degree required (for all hires after 2008)
Three years recent experience as an inpatient coder.
Certificate from accredited coding school.
CCS, HRIT RHIA or CCDS preferred

OR

Healthcare Professional:
Graduate education leading to MD, DO, or equivalent degree required
2-3 years experience in acute care, health care administration or commensurate experience
Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement

Preferred Licenses: Am Hlth Info Mgmt Assoc-AHIMA

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you’ll feel good about devoting your time and your talents.

NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.
If you wish to view NYU Langone Health’s EEO policies, please click here. Please click here to view the Federal “EEO is the law” poster or visit https://www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm for more information.

NYU Langone Health provides a salary range to comply with the New York state Law on Salary Transparency in Job Advertisements. The salary range for the role is $97,589.95 – $137,191.60 Annually. Actual salaries depend on a variety of factors, including experience, specialty, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

To view the Pay Transparency Notice, please click here