Clinical Documentation Speclst

Overview

Provides concurrent and retrospective review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Key responsibility will be to review the chart for information not currently in the chart but that is indicated by clinical indicators in the record. Queries the medical staff when necessary by written and/or verbal communication to obtain accurate andcomplete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.

Responsibilities

Establish and maintain positive relationships with patients, visitors and other employees. Interacts professionally, courteously, and appropriately with patients, visitors, and other employees. Behave in a manner consistent with maintaining and furthering a positive public perception of BronxCare Health System and its employees.

Contribute to and participate in the Performance/Quality Improvement activities of the assigned department. Contribution and participation includes data collection, analysis, implementation of and compliance with corrective/improvement activities, membership on CQI teams, consistent adherence to established performance standards and: adherence to the specific rules and regulations of the BronxCare Health System’s Safety & Security Policies; Risk Management: Incident and Occurrence Reporting; Infection Control Policies and Procedures; Patient and Customer Service.

Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholders

Meet CDI program objectives, goals, and balance scorecard metrics.

Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.

Ensure effective communications with key stakeholders.

Analyzes data, creates reports to meet desired outcomes.

Identifies trends and opportunities for improvement in clinical documentation

Meets program quality and productivity guidelines and standards.

Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.

Work effectively with CDI team members to accomplish departmental goals.

Demonstrates continued advancement in professional growth.

Qualifications

Bachelor’s

MD; MBBS or any equivalent degree

Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.

Knowledge of age-specific patient needs and the elements of disease processes and related procedures.

Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.