Clinical Documentation Specialist
BronxCare Health System
Overview
Provides concurrent and retrospective review of the clinical documentation in the medical record; review themedical record with a clinical lens to identify any missing or understated diagnoses.Key responsibility will be to review the chart for information not currently in the chart but that is indicated byclinical indicators in the record.Queries the medical staff when necessary by written and/or verbal communication to obtain accurate andcomplete physician documentation that supports the patient condition(s) and treatment plan.Performs a thorough chart review to determine the appropriate principal diagnosis of the patient.Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriatesecondary diagnoses for quality rating purposes.
Responsibilities
Meet CDI program objectives, goals, and balance scorecard metrics. Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospitaloutcomes.Ensure effective communications with key stakeholders.Analyzes data, creates reports to meet desired outcomes. Identifies trends and opportunities for improvement in clinical documentation.Meets program quality and productivity guidelines and standards.Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies. Work effectively with CDI team members to accomplish departmental goals. Demonstrates continued advancement in professional growth.
Qualifications
Bachelors degree, required.
Current MD/MBBSCDI/Coding experience preferred, but not required
Job LocationsUS-NY-Bronx
ID2024-4897
Category Administrative/Clerical
Position Type Regular Full-Time
Division Bronxcare Hospital Center - Concourse
Min USD $100,000.00/Yr.
Max USD $105,000.00/Yr.
Shift Day Shift
Department : Name Clinical Doc Specialist Depart (BHCS)
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