Clinical Documentation Improvement Specialist - DH

Join our team as a Clinical Documentation Improvement Specialist, where you'll play a vital role in enhancing the accuracy of medical records and supporting quality patient care.

What you'll be doing

• Review medical records for completeness and accuracy regarding severity of illness and quality
• Perform initial and concurrent record reviews in a timely manner
• Identify opportunities for documentation improvement
• Facilitate clinical documentation to support accurate diagnosis coding
• Formulate documentation clarifications to enhance clinical records
• Communicate with healthcare team members to ensure comprehensive documentation
• Follow up on cases and resolve documentation clarifications
• Collaborate with coding staff to ensure accurate clinical documentation

What we need to see

• BSN or equivalent degree
• 4-6 years of adult acute care experience in med/surg, critical care, emergency room, or PACU
• Minimum score of 70% on the Clinical Competency Assessment (CCA)
• New York State RN or PA license required upon hire
• Strong organizational, analytical, writing, and interpersonal skills
• Critical thinking and problem-solving abilities
• Basic computer skills and familiarity with Windows-based software
• Knowledge of pathophysiology, disease processes, and coding guidelines

Ways to stand out from the crowd

• Knowledge of official coding guidelines related to the Inpatient Prospective Payment System
• Physician Assistant license from the New York State Board of Medicine