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Clinical Documentation Specialist II

Full/Part Time: Full Time
Location/Affiliates: Mount Sinai Hospital (Queens)
Department: 331 - Clin Document Mgnt
Requisition Number: 14-1658174

Job Description:

The Clinical Documentation Specialist 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.

1.Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records.

2.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) payor.

3.Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.

4.Updates the DRG worksheet to monitor any changes in status, procedures/treatments, and confers with physicians in order to assign accurate DRG.

5.Proactively solicits clarification from physicians to ensure points of clarification have been recorded in the patient's chart.

6.Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payor regulations.

7.Reconcile DRG difference between Coding staff and CDS.

8.Educates nursing staff, and other clinicians on compliant documentation and accurate coding as well as serve as clinical liaison to the coding.

9.Performs other related duties

Job Qualifications:

1-2 years of CCA, CCS or CCDS

Associates Degree

Microsoft Word and Excel- Intermediate, 3M encoder

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-9 codes, DRG and CPT coding

Mount Sinai Medical Center is an equal opportunity/affirmative action employer. We recognize the power and importance of a diverse employee population and strongly encourage applicants with various experiences and backgrounds. Mount Sinai Medical Center--An EEO/AA-D/V Employer.

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