Clinical Documentation Quality Improvement Specialist II-Mount Sinai Brooklyn - Full-time - Day

The Clinical Documentation Quality Improvement Specialist II is responsible for improving the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that documentation reflects complete and accurate level of service rendered to patients. Performance Requirement for CDQI Specialist II 1. Experienced CDQI with minimum 2-4 years recent experience in CDI role 2. To meet quality and quantity expectations within 6 months of employment 3. Quality review: ≥ 93%; 4. Quantity: 10-14 Initial Chart reviews, >5 agree queries per work days. 5. Attains Clinical Documentation Specialist certification through ACDIS or AHIMA 6. The CDI specialist II also assists leadership in utilizing expertise in CDI and data analysis in evaluating CDI accuracy, standardizing review findings and reporting out results 7. Works effectively and efficiently, able to work on several things at once while maintaining expected productivity outcomes. Meets established productivity goals without sacrificing quality.

Roles & Responsibilities:

• Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records
• Facilitates accurate clinical documentation to ensure appropriate DRG classification is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer
• Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.
• Ability to write queries that are concise and easily understood by the queried provider, in order to garner additional necessary documentation in the inpatient medical record
• Timely reconciliation of all cases, to include accurate recording of DRG or SOI impact based on physician query, as well as physician response to all queries
• Identify query opportunities, diagnoses not supported by clinical indicators, and function on par with other CDI team members
• Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team
• Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisor
• Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.
• Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data and clinical validation.
• Performs other related duties.

Requirements:

• 2 years of CCS, CDIP or CCDS or equivalent 
• Good written, oral and interpersonal skills 
• Excellent problem solving and analytical skills 
• Strong organization skills  
• Attention to details 
• Strong computer skills 
• Demonstrated knowledge of ICD-10 CM/PCS codes, DRG and CPT coding