Clinical Documentation Specialist, Level 1

About NYC Health + Hospitals

NYC Health + Hospitals/Bellevue is America’s oldest public hospital, established in 1736. Affiliated with the NYU School of Medicine, the 844-bed hospital is a major referral center for highly complex cases, with its 6,000 employees including highly skilled, interdisciplinary clinical staff. It sees more than 110,000 emergency room visits and 500,000 outpatient visits annually. Bellevue is an academic medical institution of international renown. We have served as an incubator for major innovations in public health, medical science, and medical education. Bellevue is a Level I Trauma Center delivering around-the-clock care in adult, pediatric, psychiatric and pediatric psychiatric emergencies as well as in the nationally-designated categories of cardiology, neurology, toxicology, and neonatology. In addition to providing comprehensive inpatient and outpatient state-of-the-art care Bellevue is a city-wide medical specialty referral source. Bellevue’s clinical centers of excellence include: Emergency Medicine and Trauma Care; Cardiovascular Services; Designated Regional Perinatal Center and Neonatal Intensive Care Unit (ICU); Comprehensive Children’s Psychiatric Emergency Program; and Cancer Services.

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.

Job Description

Purpose of Position:

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.

Summary Of Responsibilities

• 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 (diagnosis related group) and SOI (severity of illness).
• Electronically and 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.
• Utilizing cording staff expertise and references to assist in adhering to established coding guidelines.
• Conduct educational in-services for medical staff; attend and participate in educational in-services.
• Other duties as assigned by Supervisor or designee.
  
  

Minimum Qualifications

• 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
• 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
• 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
• Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience; or
• Successful completion of education that leads to a medical degree; and two (2) years of experience,as described in “4” above.
  
  

How To Apply

If you wish to apply for this position, please apply online by clicking the "Apply Now" button.

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