Clinical Documentation Specialist Level I

Lincoln Medical and Mental Health Center is one of New York City's premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered. Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women's Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Visit us at www.nyc.gov/html/hhc/lincoln.

Job Description

Purpose of Position:

Clinical Document Specialist (CDIS): under the supervision of the leadership of the Director of Health Information Management or designee is responsible to review medical records for appropriate documentation that will assist to enhance appropriate documentation that will enhance reimbursement, and improve documentation in order to be in-compliance with regulatory agencies and reduce denials.

Duties and Responsibilities:

• Facilitate appropriate clinical documentation to ensure level of services and acuity of care are accurately reflected in the medical record.
• Perform admission review for the designated patient population using clinical documentation guidelines; Extensively review all physician and other clinical documentation, lab results, diagnostic information, and treatment plans to capture appropriate information on to Epic CDI module.
• Utilize clinical skills to identify documentation opportunities to reflect appropriate severity of illness, acuity, and resource consumption and facilitate optimal revenue enhancement, where appropriate.
• Propose principal diagnosis, co-morbid conditions, complications, procedures and, appropriate working DRG (diagnostic related group) and SOI (severity of illness).
• Electronically & verbally communicates with appropriate physician(s) and ancillary personnel concurrently to ensure documentation opportunities are clarified.
• Generate physician query form (communication tool to physician) to inquire about documentation.
• Update DRG review worksheet within Epic to reflect any change in patient status, procedures/treatments, confers with physician to finalize diagnoses and change in proposed working DRG assignment.
• Communicate with physician and conducts timely follow-up medical record review to ensure requested documentation recorded in the medical record.
• Review and discuss clinical issues and documentation opportunities with coding staff to determine appropriate DRG. Review and discuss significant DRG assignment variations
• (working vs. final) with DRG Validator/Coding staff.
• Utilize coding staff expertise and references to assist in adhering to established coding guidelines.
• Conduct educational in-services for medical staff; attend and participate in educational inservices.

Minimum Qualifications
1. Valid New York State license and current registration to practice as a Registered Professional Nurse(RN) issued by the New York State Education Department (NYSED); and Bachelor of Science inNursing degree from an accredited college or university; and four (4) years of acute care experience;or
2.Valid New York State license and current registration to practice as a Nurse Practitioner (NP) issuedby the NYSED; and two (2) years of experience, as described in "1" above; or
3.Valid New York State license and current registration to practice as a Physician Assistant (PA)issued by the NYSED; and two (2) years of experience, as described in "1" above; or
4.Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience; or
5.Successful completion of education that leads to a medical degree; and two (2) years of experience as described in "4" above.

If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:

Lincoln Medical & Mental Health Center
Human Resources Department
234 Eugenio Maria De Hostos Blvd, (East 149th Street),
2nd Floor, Annex
Bronx, NY 10451
Attn: Recruitment Unit

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs