Job DescriptionThe MSHS Clinical Documentation Quality Coordinator supports multiple acute care hospitals within the systems department for Clinical Documentation Quality Improvement (CDQI).
The Quality Coordinator is responsible for performing quality reviews on medical records to validate ICD -10 CM/PCS codes, DRG appropriateness, missed secondary diagnoses and procedures, and ensure compliance and accuracy of the MS-DRG and APR DRG throughout the MS Health System. Also, provides clinical documentation and coding education to Clinical Documentation Improvement (CDI) specialists, medical staff, midlevel providers and others. Remains accessible as a subject matter expert for MSHS regarding documentation, reimbursement and data interpretation as it relates to inpatient records. The Clinical Documentation Quality Coordinator conducts the quality review of inpatient CDI cases, queries, assigned codes and working DRG and participates in process improvement activities based on audit results and hospital or institute performance improvement projects impacted by documentation.
Responsibilities1.Performreviews of inpatient records to:
a.Evaluatedocumentation to assign the principal diagnosis, pertinent secondary diagnoses,and procedures for accurate and optimal DRG assignment;
b.Evaluateappropriateness of documentation to support quality standards including PSIs,HACs ;
c.Identifymissed secondary diagnoses and procedures;
d.Queryclinicians to achieve improved clinical documentation and accurate coding foroptimal allowable reimbursement;
e.PerformDRG reconciliation and inform HIM of any recommended coding changes.
2.Analyzereports and identifies trends and statistical significance in codingopportunities as well as CDI opportunities that will assist in theorganizational process of documentation improvement.
3.Workclosely with the CDI, HIM and Quality team to provide feedback ensuring codingconsistency and accuracy meeting the requirements of: ICD-10 CM/PCS, UHDDS andsequencing guidelines, Federal and State regulations, American HospitalAssociation Coding Guidelines and Coding Clinic.
4.Educateand mentor new employees through the on-boarding process. Trains CDI staff oninitial CDI review and query process and provide on-going education related tonew topics in CDI, coding and reimbursement.
5.Providefeedback to HIM management staff and CDI leadership regarding opportunities fordocumentation improvement and participates with the planning and development ofeducational programs directed towards improving documentation.
6.Developand maintains compliant query templates as needed due to annual changes in theInpatient Prospective Payment System (IPPS) and AHA Official Coding Guidelinesand Coding Clinics.
7.GenerateMSHS CDI policies and guidelines in accordance with AHIMA Practice Briefs,Official Coding Guidelines, ACDIS standards and Coding Clinic.
8.Collaboratewith the CDI Manager in the analysis of CDIS reports and other statisticalreviews.
9.Assistwith the analysis of PSIs and HACs to ensure that the coding assignment wasproperly assigned based upon review of the medical documentation andapplication of coding guidelines.
10.Maintain confidentiality ofinformation acquired pertaining to patients, physicians, associates, andvisitors to the Hospital. Discusses patient and hospital information only amongappropriate personnel in private places.
11.Assumes responsibility forperformance of job duties in the safest possible manner, to assure personalsafety and that of co-workers, and to report all preventable hazards and unsafepractices immediately to management.
12.Responsible for remainingcurrent with the latest healthcare technology and coding advice through readingavailable coding literature, attendance of seminars and in-services, internetresearch and other educational resources for inpatient and outpatientreimbursement and coding.
13.Participates in educationprograms to maintain up to date coding skills.
14.Consistently meetsestablished productivity targets for work assignments.
15.Participates in staff andmanagement meetings as they relate to HIM and CDI initiatives.
16.Other duties as assigned
Qualifications- Bachelors Degree, minimum (preferred: Nursing or Information Systems or related)
- Registered Health Information Administrator or Registered Health Information Technician or equivalent experience preferred
- 5 years of related experience (greater preferred), working in acute care hospital or similar setting
- Certified Coding Specialist Certification (CCS, CCS-P) required
Compensation StatementThe Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $96,461.00 - $144,692.00 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.
Non-Bargaining Unit, 331 - Clinical Document Mgnt - MSH, Mount Sinai Hospital
