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. If you’re a skilled healthcare professional who values teamwork and excellence in patient care, then Montefiore Nyack Hospital could be your perfect match. As part of the Montefiore Health System, we offer the quality of a premier academic medical center and the caring of a community hospital. We’re committed to the health and well-being of Rockland County’s residents and our team members, and offer flexible opportunities for per diem, part-time and full-time employment. Team members benefit from: Robust compensation package, including competitive pay, medical benefits, tuition reimbursement and more Outstanding professional staff The clinical excellence of the Montefiore Health System Opportunities for growth through training and continuing education Equal Opportunity Employment Zero tolerance policy for discrimination, harassment and abuse Fair employment practices, including equal treatment in hiring, promotion and compensation WE CARE code of conduct for all team members ust 35 miles from New York City, Rockland County offers friendly communities, natural beauty, outdoor pursuits, convenient shopping and easy access to New York City. While Rockland County has plenty to offer, both the mountains and the beach are within a few hours’ drive. Rockland is an area full of history and has a vibrant arts scene with museums, theaters, music venues, cultural events and festivals. Learn more about cultural events in Rockland County. With over 3,000 acres of parks, Rockland County is a Preserve America Community protecting open spaces and uncluttered skylines. The county offers trails, dog runs, historic landmarks, water activities, golf and horseback trails. Learn more about outdoor activities in Rockland County. One of the top dining areas in the Hudson Valley, Rockland County features award-winning chefs and a growing craft beverage scene. Shopping options range from independent boutiques in quaint downtowns to the Palisades Center mall, a four-level shopping experience. Learn more about dining and shopping in Rockland County. Safe, thriving communities with outstanding schools and healthcare make Rockland County ideal for both professionals and families. Whether you’re growing your family and looking for good schools and family-friendly neighborhoods or growing your career and looking for higher education opportunities close to home, Rockland County has what you need.