Clinical Documentation Quality Improvement Coordinator-Quality Dept- FT Days Remote
Mount Sinai Health SystemThe MSHS Clinical Documentation Quality Coordinator supports multiple acute care hospitals within the systems department for Clinical Documentation Quality Improvement (CDQI).
The Quality Coordinator is responsible for performing quality reviews on medical records to validate ICD -10 CM/PCS codes, DRG appropriateness, missed secondary diagnoses and procedures, and ensure compliance and accuracy of the MS-DRG and APR DRG throughout the MS Health System. Also, provides clinical documentation and coding education to Clinical Documentation Improvement (CDI) specialists, medical staff, midlevel providers and others. Remains accessible as a subject matter expert for MSHS regarding documentation, reimbursement and data interpretation as it relates to inpatient records. The Clinical Documentation Quality Coordinator conducts the quality review of inpatient CDI cases, queries, assigned codes and working DRG and participates in process improvement activities based on audit results and hospital or institute performance improvement projects impacted by documentation.
Responsibilities
1.Perform reviews of inpatient records to:
a.Evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate and optimal DRG assignment;
b.Evaluate appropriateness of documentation to support quality standards including PSIs, HACs ;
c.Identify missed secondary diagnoses and procedures;
d.Query clinicians to achieve improved clinical documentation and accurate coding for optimal allowable reimbursement;
e.Perform DRG reconciliation and inform HIM of any recommended coding changes.
2.Analyze reports and identifies trends and statistical significance in coding opportunities as well as CDI opportunities that will assist in the organizational process of documentation improvement.
3.Work closely with the CDI, HIM and Quality team to provide feedback ensuring coding consistency and accuracy meeting the requirements of: ICD-10 CM/PCS, UHDDS and sequencing guidelines, Federal and State regulations, American Hospital Association Coding Guidelines and Coding Clinic.
4.Educate and mentor new employees through the on-boarding process. Trains CDI staff on initial CDI review and query process and provide on-going education related to new topics in CDI, coding and reimbursement.
5.Provide feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement and participates with the planning and development of educational programs directed towards improving documentation.
6.Develop and maintains compliant query templates as needed due to annual changes in the Inpatient Prospective Payment System (IPPS) and AHA Official Coding Guidelines and Coding Clinics.
7.Generate MSHS CDI policies and guidelines in accordance with AHIMA Practice Briefs, Official Coding Guidelines, ACDIS standards and Coding Clinic.
8.Collaborate with the CDI Manager in the analysis of CDIS reports and other statistical reviews.
9.Assist with the analysis of PSIs and HACs to ensure that the coding assignment was properly assigned based upon review of the medical documentation and application of coding guidelines.
10.Maintain confidentiality of information acquired pertaining to patients, physicians, associates, and visitors to the Hospital. Discusses patient and hospital information only among appropriate personnel in private places.
11.Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.
12.Responsible for remaining current with the latest healthcare technology and coding advice through reading available coding literature, attendance of seminars and in-services, internet research and other educational resources for inpatient and outpatient reimbursement and coding.
13.Participates in education programs to maintain up to date coding skills.
14.Consistently meets established productivity targets for work assignments.
15.Participates in staff and management meetings as they relate to HIM and CDI initiatives.
16.Other duties as assigned
Qualifications
- Bachelors Degree, minimum (preferred: Nursing or Information Systems or related)
- Registered Health Information Administrator or Registered Health Information Technician or equivalent experience preferred
- 5 years of related experience (greater preferred), working in acute care hospital or similar setting
- Certified Coding Specialist Certification (CCS, CCS-P) required
Compensation Statement
The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $96,461.00 - $144,692.00 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.
Non-Bargaining Unit, 331 - Clinical Document Mgnt - MSH, Mount Sinai Hospital