• Clinical Documentation Specialist

    St. Mary's Healthcare (Amsterdam, NY)


    Job Requisition: REQ3763 Employment Type: Per Diem Shift: Days Hours Per Week: As scheduled

     

    Hiring Range: $ 35.53- $ 46.19

     

    The actual compensation for this position will be determined based on experience and other factors permitted by law.

     

    Responsibilities: • Completes admission reviews and assigns a working Diagnosis Related Group. Ensures the working DRG and other information are entered in the Clinical Documentation Improvement database.

     

    • Initiates and maintains extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.

    • Collaborates with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.

    • Maintains accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.

    • Understands MCG criteria as well as Interqual • Updates live coding and PQF live time as well as inpatient or observation status

    • Works with Finance and coding to maximize documentation, ensure compliance and reduce denials

    • Works with case management and the admit process on medical necessity

    Licensure / Certification / Registration:

    • Required Credential(s): • One or more of the following:

    • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.

    • Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.

    • Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.

    • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.

    • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.

    • Registered Nurse credentialed from the New York Board of Nursing obtained prior to hire date or job transfer date.

     

    Preferred Credentials RN or LPN or NP or PA

     

    Education: Associates degree, or Bachelors degree required

     

    Must be able to speak, read, write and follow instructions in English.