Clinical Documentation Quality Improvement
3 weeks ago
**Description**
The Clinical Documentation Quality Improvement Specialist is responsible for improving the overall quality and completeness of clinical documentation; 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.
**Performance Requirement for CDQI Specialist I**
1. Experienced CDQI with minimum 1 to 2 years recent experience in CDI role
2.To meet quality and quantity expectations within 6 months of employment.
3. Quality review: = 90%;
4. Quantity**:10-14 Initial Chart reviews, **>**4 agree queries per work days**.
**Responsibilities**
1. Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records.
2. Facilitates accurate clinical documentation to ensure appropriate DRG classification is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer.
3. Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.
4. Writes queries that are concise and easily understood by the queried provider, in order to garner additional necessary documentation in the inpatient medical record
5. Timely reconciliation of all cases, to include accurate recording of DRG or SOI impact based on physician query, as well as physician response to all queries
6. Identifies query opportunities, diagnoses not supported by clinical indicators, and function on par with other CDI team members.
7. Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team
8. Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations.
9. Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
10. Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.
11. Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data and clinical validation.
12. Performs other related duties.
**Qualifications**
- Bachelor Degree preferred
- 1-2 years of CCA, CCS, CDIP or CCDS or equivalent
- Familiar with APC coding and identifies front-end process improvement initiatives
- Familiar with HCC codes - preferred
- Thorough knowledge of ICD-9-CM, ICD-10, CPT, and HCPCS - preferred
- License: RN license, Medical graduates, NPs or PA
- Certification: CCA, CCS, CDIP or CCDS
**Compensation Statement**
The 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 this role is $72,472.00 - $99,317.69 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.
Non-Bargaining Unit, E01 - Partner MSO Services - MSH, Mount Sinai Hospital
**Employer Description**
**Strength Through Diversity**
The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:
- Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.
- Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.
- Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.
At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance
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