Documentation Specialist

NYU Medical Center   •  

New York, NY

5 - 7 years

Posted 239 days ago

This job is no longer available.

Job Responsibilities:

  • 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
  • Assists with special projects as needed and perform related duties as assigned.

Minimum Qualifications:
To qualify, you must be an RN, Coder, or Healthcare Professional.
Bachelors 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 for Registered Nurse or Physician Assistant
CCDS preferred

  • Coder: 
    • Bachelors degreerequired (for all hires after 2008)
    • Three years recent experience as an inpatient coder.
    • Certificate from accredited coding school.
    • CCS, HRIT RHIA or CCDS preferred
  • Healthcare Professional: 
    • Graduate education leading to MD, DO, or equivalent degreerequired
    • 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

Job ID: 1037936_RR00016744