RN Clinical Documentation Specialist

City/State:

Nyack, New York

Department:

Clinical Documentation Improvement

Work Shift:

Day

Work Days:

DAYS VARY

Scheduled Hours:

10 AM-6 PM

Scheduled Daily Hours:

8 HOURS

Hours Per Pay Period:

0

Pay Rate/Range:

$53.00- $59.00

Job Summary

Responsible for facilitating improvement of inpatient medical record documentation by intervening, interacting with, and educating physicians and other licensed independent practitioners. Clinical Documentation Specialists will review the documentation and coding sequence for impact it has on potential denials, patient safety indicators/quality, hospital acquired conditions, and the mortality index.

Essential Functions

• C. Job Specific Contacts

  1. General Contacts: CMO, Medical Staff, Quality, HIM and other healthcare professionals

  D. Environment and Demands

  1. Environmental Demands: Remote with occasional onsite presence

  2. Essential Requirement: Dedicated Home office space, HIPPA compliant, Wi-Fi access, telephone access,

  B. MISSION/STRATEGIC PLAN:

  Demonstrates support of the mission and strategic action plan through the initiation and ongoing implementation/evaluation of department activities/plans.

  C. JOB SPECIFIC COMPETENCIES:

  Demonstrates the technical/professional knowledge, skills and abilities necessary for the successful operations of the department including:

  1. Performs inpatient documentation audit and review.

  2. Develops process to identify opportunities for documentation improvement, intervenes with attending physicians and facilitates improvement in electronic medical record documentation (EPIC).

  3. Interacts with medical staff and others relative to documentation improvement.

  4. Conduct one to one teaching for physicians and educates physicians/practitioners regarding documentation and its effects.

  5. Initiates and maintains records and databases to quantify impact of interventions and ensure follow through of recommendations.

  6. Identifies, investigates and evaluates practices and processes to facilitate continuous improvement in complete and accurate medical record documentation, including second level reviews as needed.

  7. Coordinates clinical information from various sources and databases in order to develop recommendations for documentation.

  8. Educates department personnel from individual expertise and experience.

  Part II: Employee Performance Standards:

  A. CUSTOMER SERVICE:

  1. Demonstrates personal excellence in customer service for both internal and external customers.

  2. Holds staff accountable for the delivery of excellent customer service.

  3. Participates in team efforts to increase the level of customer satisfaction.

  B. PERFORMANCE IMPROVEMENT:

  1. Demonstrates the ability to recognize an opportunity for improvement and to collect and assess data.

  2. Demonstrates the ability to develop, implement and evaluate a Performance Improvement Plan.

  3. Participates in Departmental/Hospital-wide activities which improve processes/outcomes.

  4. Utilizes resources to maintain and improve self knowledge and development and fosters the same for employees.

  5. Demonstrates compliance with licensure/certification requirements and the timeliness of their submission.

  C. BUDGET:

  1. Collaborates with employees to control costs and pursue additional revenue opportunities.

  D. PROJECTS/ASSIGNMENTS:

  1. Completes projects/assignments within projected time frames and expectations.

Qualifications

• BSN Preferred
• Current CDI experience in conjunction with strong med/surg clinical experience
• Working with Quality, HIM, Infection Control, Physicians
• Clear interpersonal and communication skills.
• Analytical skills to interpret medical record documentation and departmental metrics.
• Self-motivated individual with critical thinking skills.
• Ability to work independently with minimal supervision.
• Computer knowledge of Excel, Word and Power Point required. Must be detail orientated.
• Knowledge of 3M and EPIC.
• CCDS - Certified Clinical Documentation Specialist - ASSOCIATION OF CLINICAL DOCUMENTATION INTEGRITY SPECIALISTS (ACDIS) Preferred
• Registered Nurse New York - New York State Board of Nursing Required

Montefiore Nyack Hospital is an equal employment opportunity employer. Montefiore Nyack Hospital will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.