Clinical Documentation Quality Improvement Specialist III-Mt Sinai Hospital

The Clinical Documentation Specialist III is a senior technician, responsible for improving the overall quality and completeness of clinical documentation, and proficient in all three grouper systems. Expert knowledge of ICD-10 CM/PCS and all current regulations. This individual 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. Assumes responsibility for education of clinicians and project management as required.

1. Proficient in all (3) grouper systems, facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records.

2. Facilitates modification of clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer under Medicare.

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

4. Assists in medical screening process, making referrals, interacting with case managers and clinical nurse specialists to ensure continuity of patient care as needed.

5. Updates the DRG worksheet to monitor any changes in status, procedures/treatments, and confers with physicians to finalize diagnoses.

6. Proactively solicits clarification from physicians to ensure points of clarification have been recorded in the patients chart

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

8. Reviews clinical issues with coding staff to assign a working DRG.

9. Educates nursing staff, patient caregivers and coding staff on compliant documentation opportunities, coding and reimbursement issues as well as provides clinical expertise to the coding staff. Takes a lead role in education and mentoring less senior staff.

10. Performs other related duties.

• RN/BSN or related health care professional preferred, with experience in med-surgical, critical care or emergency care a plus. Eligible for CAC, CCS or CCDS.
• 5 years minimum, greater preferred, as health care professional (experience in med-surgical, critical care or emergency care is desirable).
• Knowledge of ICD-10 CM/PCS and current Medicare and Medicaid regulations regarding clinical documentation and billing compliance for Part A and B services