Document Improvement Specialist

Montefiore · $104,000–$130,000 (stated in the posting)

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Job Summary

The Documentation Improvement Specialist maintains professional practice standards, clinical expertise, and demonstrates leadership skills. She/He participates in assigned projects  designed to continually improve hospital performance targets at the medical center (e.g auditing, service line education, etc.). She/he is responsible for validating the integrity of the medical record documentation in the overall completeness, accuracy, specificity and timeliness of  documentation through extensive medical record and query process interrogation.  

Conducts successful interventions related to documentation improvement and coding validation, and follows through with all software and supervisory recommendations based on their individual impact. Additionally, effective communication with appropriate clinical and coding staff, and utilization of all required computer programs and software is integral. 

Identifies, investigates, evaluates practices and processes to facilitate continuous improvement in complete and accurate medical record documentation while maintaining records and databases to quantify the deficits. Maintains knowledge of regulatory requirements and policies regarding required
documentation impact on coding, and DRG assignments AND CMS AND NEW YORK STATE HOSPITAL QUALITY PERFORMANCE DATA PROGRAMS . Monitors key indicator metrics associated with CDI, as they relate to revenue cycle and quality outcomes. 

Responsibilities

• Completes concurrent and retrospective validation of system output (principal diagnosis, pertinent secondary diagnoses, post-admission complications, Present on Admission Status (POA), Hospital Acquired Conditions (HACs), Patient Safety Indicators (PSIs), procedures, and electronic queries for accurate Diagnosis-Related Group (DRG) assignment and Case Mix Index (CMI), risk of mortality, and severity of illness).

• Provides routine in-services to assigned clinical areas/service lines regarding regulatory documentation
  requirements including feedback on the impact of clinician documentation on service specific metrics.  

• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for performance improvement (i.e. :  trends responses to
  queries and completion, service  line statistics, population specific query opportunities)

• Required consistent resource for clinical/service units; acts as a key support for physician and physician extenders on interpretation and application of documentation integrity,  documentation standards, and other related actions and matters; provides complete follow-through on all requests for clarification.

• Assists in the orientation and training of new staff members, and provides continual guidance and mentoring, as required. 

• Integrates management/
  leadership skills into daily
  clinical/administrative
  practice.

• Collaborate with Health Information Management for review of denials based on clinical documentation queries and providing supporting documentation.

• Performs auditing functions on staff, including revalidation of assigned accounts, queries, and producing reports/tallies of quality of work (e.g. accuracy rates, educational opportunities, query per review rate).

• In manager's absence, assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians.

• Implements and substantiates CDIS software  recommendations, therefore augmenting end user actions and productivity. 

• Interfaces appropriately with software output for measurable outcomes and enhancement of the legal medical record.

Required

• Microsoft Excel, Power Point, 3M system application, Outlook

• Prior experience in training peers and expertise in group presentations

• Working knowledge of Medicare,  and All Payer Refined, reimbursement systems and coding structures.

• Self-motivated individual with cognitive thinking skills who is able to work independently with minimal supervision.

• Intellectual curiosity and desire to learn new skills
  Knowledge of age-specific needs and the elements of disease processes and related procedures.

• Prior  documentation improvement program is a plus.

• 3 years leadership/supervisory experience

• Knowledge of coding concepts and related to coding or experience with hospital finance or hospital billing.

• Excellent verbal and written communication skills

• Ability to work with providers, coders and other nurses, as well as the ability to problem solve and meet daily work productivity goals.

• Teaching and presentation skills are required.

• Excellent critical thinking skills are required.

• OHS Annual Assessment

• Bachelor's Degree in a healthcare related field

• CERTIFICATION IN CODING AND DOCUMENTATION INTEGRITY WITHIN THREE YEARS OF EMPLOYMENT IN THIS POSITION WITH ONGOING MAINTENANCE OF SUCH CERTIFICATION

• 3 years minimum of healthcare experience

Preferred Education and Certifications

• CCS, CDIP, RN,PA, NP, MD, CCDS  or trained Physician background
  or greater that 5years DRG experience.  

• Master's Degree in a healthcare related field

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