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Job Description

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.

Qualifications

+ 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

Responsibilities

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.

About Us

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.

Compensation Statement

Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $87692 - $131538 Annually. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.