Clinical Documentation Improvement Specialist - SUNY Downstate Health Sciences University : Job Details

Clinical Documentation Improvement SpecialistJob No: 496492 Department: MEDICAL RECORDS Local Title: Clinical Documentation Improvement Specialist Budget Title: Th Utilization Review and Quality Assurance Senior Coordinator Work Type: Full Time Location: Brooklyn, NY Categories: Administrative, ClinicalAre you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors.Bargaining Unit:UUPJob Summary:The Department of Health Information Management at SUNY Downstate Health Sciences University is seeking a full time Clinical Documentation Improvement Specialist / TH Utilization Review & Quality Assurance Senior Coordinator. The successful candidate will:

• Will report to the CDI Manager and Director of Health Information Management.
• Be responsible for reviewing medical records to facilitate clinical documentation that accurately reflects the patients' severity of illness and risk of mortality by improving the quality of the physicians' clinical documentation. This involves extensive record review, interaction with physicians, residents, advanced practice nurses, ancillary providers, coding and HIM professionals and nursing staff.
• Review inpatient medical records for identified payer populations (Medicare, Medicaid, Blue Cross/Blue Shield, and others as designated) as directed on admission and throughout hospitalization.
• In collaboration with physician leadership, design and implement specific tools to support medical record physician documentation.
• Develop and implement plans for both formal and informal education of physician, nursing, and other clinical staff.
• Communicate with attending physician and other relevant clinical staff, either verbally or through written methodology.
• Maintain good rapport and cooperative relationships.
• Approach conflict in a constructive manner.
• Help identify problems, offers solutions, and participates in their resolution.
• Assure personal and professional growth through self-study/attendance/participation in seminars and workshops.
• Maintain the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to the Medical Center.
• Behave in accordance with Mission, Vision, and Values of the Medical Center.
• Demonstrate integrity, truthfulness and fairness when working with others.
• Create an environment of acceptance and respect in the work place.
• Integrate knowledge of cultural competence and inclusion in all daily practices such as assessment, documentation, communication, etc.
• Work closely with HIM coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient clinical status and care.
• Contribute to organizational, departmental and unit-based process improvement activities.
• Demonstrate and maintain competency and accuracy in use of software applications including capability in Microsoft Office applications.
• Conduct daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity.

Required Qualifications:

• Registered Nurse with 3+ years of acute care nursing experience with New York State Registered Nurse Licensure;
  • Or DO, MBBS, or foreign educated medical graduate;
  • Or 2 to 3 years of Clinical Documentation Improvement experience.
• Excellent interpersonal skills, including verbal and written communication, to develop relationships necessary to influence physician document process.
• Ability to prioritize and be self-directed and capable of independent decision making.
• Analytic skills necessary to clinically assess medical records.
• Critical thinking, problem solving and deductive reasoning skills.
• Ability to organize and present information clearly and concisely.
• Basic computer skills including Microsoft products Office, Excel and PowerPoint.
• Working knowledge of Medicare reimbursement and coding structures.

Preferred Qualifications:

• Certification in Clinical Documentation Improvement preferred.

Work Schedule:Monday to Friday; 9:00am to 5:00pm (Full-Time)Salary Grade/Rank: SL-4Salary Range: Commensurate with experience and qualificationsExecutive Order:Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor's Office of Employee Relations at (518) ###-#### or via email at [email protected] Employment Opportunity Statement:SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws.Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply.If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at [email protected]Advertised: August 20, 2024 Eastern Daylight Time Applications close: