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Descriptive Title: Clinical Documentation Specialist
Budget Title: TH Staff Associate
State Professional Position
Department: Health Information Management
State Line#: 13087
Campus: Stony Brook-University Hospital
Salary: Commensurate with experience
Required Qualifications: Current NYS RN License with Bachelors Degree or advanced licensure of Nurse Practitioner or Physician Assistant. Minimum of five years hospital acute care nursing experience. Computer proficiency with a working knowledge of Word, Excel and Powerpoint. Excellent written and verbal communication skills. Critical thinking and interpersonal skills to build effective relationships with physician, case management, nursing and HIM Staff.
Preferred Qualifications: Previous clinical documentation improvement experience. CCDS credential. Formal CDS training. CT/ICU or cardiology clinical experience. Recent quality management, core measure or clinical decision support experience.
Brief Description of Duties:
- Improves the overall quality and completeness of concurrent inpatient documentation by performing initial and follow up reviews to facilitate appropriate reimbursement and compliance with performance measures.
- Interacts and communicates with physician staff daily, clarifying documentation in the medical record through verbal, electronic and paper query. Providing follow up to ensure points of clarification have been recorded in the medical record.
- Identifies appropriate principal diagnosis to establish a working DRG assignment and average length of stay. Maintain DRG worksheet to include abstraction of patient's clinical findings relevant to principal and secondary diagnosis and procedures.
- Demonstrates knowledge of DRG payer issues, appropriate DRG assignment alternatives, clinical documentation requirements of core measures and improves the overall quality and completeness of the medical record.
- Works in coordination with the Physician Advisor and Assistant Director of CDI to develop and present physician and staff education on documentation, coding, quality and regulatory performance.
- Works in coordination with coding specialists to ensure appropriate reimbursement based on clinical level of service.
- All other duties as assigned.
Special Notes: Full-time day 8am-430pm position. Please note Stony Brook Medicine is a smoke free environment. All Hospital positions are subject to changes in pass days and shifts as necessary. This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
*Repost: change in qualifications.
Please note: Prior to start date , the selected candidate must meet the following requirements: Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services, clear a background investigation; submit (3) written references, and provide a copy of the required license(s)/certificate(s). Please be advised that failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.
The selected candidate must successfully clear a background investigation.
Stony Brook University - 20 months ago