Clinical Documentation Specialist
Company: Northwell Health
Location: Mount Kisco
Posted on: January 27, 2023
Job Description:
Job Description
Job Description
Facilitates and obtains appropriate clinical documentation for all
clinical conditions or procedures to support the appropriate
severity of illness, expected risk of mortality, and complexity of
care provided. Responsible for concurrent inpatient medical record
reviews for Medicare, Medicaid and all commercial payers. Generates
queries and have follow up discussions with physicians for
clarification of ambiguous or conflicting documentation.
Job Responsibility
- Facilitates modifications to clinical documentation supporting
appropriate reimbursement is received for the level of service
rendered to all patients.
- Demonstrates knowledge of payor issues, documentation
opportunities, clinical documentation requirements, and referral
policies and procedures.
- Improves the overall quality and completeness of clinical
documentation by performing admission/continued stay reviews using
clinical documentation (CD) guidelines.
- Ensures the accuracy and completeness of clinical information
used for measuring and reporting physician and Hospital
outcomes.
- Assists in screening process, making referrals, interacting
with medical staff, and various departments to ensure continuity of
patient care.
- Process discharges to reflect any changes in status,
procedures/treatments, and conferring with physician to finalize
diagnoses.
- Educates medical and coding staff on clinical documentation
opportunities, coding and reimbursement issues, as well as
performance improvement methodologies.
- Conducts follow-up reviews of clinical documentation to ensure
points of clarification have been recorded in the patient's chart;
reviews clinical issues with coding staff.
- Tracks response to queries; serves as a member of the CDI Work
Group.
- Operates under general guidance and work assignments are varied
and require interpretation and independent decisions on course of
action.
- Performs related duties as required. All responsibilities noted
here are considered essential functions of the job under the
Americans with Disabilities Act. Duties not mentioned here, but
considered related are not essential functions.
Job Qualification
- Graduate from an accredited School of Nursing required. Must
obtain a Bachelor of Science in Nursing degree within 5 years of
employment date.
- Current License to practice as a Registered Professional Nurse
in New York State required, plus specialized certifications as
needed.
- 1-3 years of relevant experience, required.
*Additional Salary Detail
The salary range and/or hourly rate listed is a good faith
determination of potential base compensation that may be offered to
a successful applicant for this position at the time of this job
advertisement and may be modified in the future.When determining a
team member's base salary and/or rate, several factors may be
considered as applicable (e.g., location, specialty, service line,
years of relevant experience, education, credentials, negotiated
contracts, budget and internal equity).
Keywords: Northwell Health, Stamford , Clinical Documentation Specialist, Healthcare , Mount Kisco, Connecticut
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