Clinical Documentation Specialist

3 weeks ago


New York, New York, United States NYU Langone Health Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Specialist to join our team at NYU Langone Health. As a Clinical Documentation Specialist, you will play a critical role in improving the quality and accuracy of clinical documentation, ensuring that our medical records are complete, accurate, and compliant with regulatory requirements.

Key Responsibilities
  • Improve the quality and accuracy of clinical documentation through extensive interaction with physicians, nursing staff, and other patient caregivers.
  • Ensure the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.
  • Collaborate with Coding to maintain coding and documentation quality and compliance.
  • Work closely with medical staff to continuously improve clinical documentation and facilitate accurate coding.
  • Develop and implement education programs for clinical and non-clinical staff on documentation best practices.
  • Stay up-to-date with the latest developments and advancements in documentation improvement and coding.
Requirements

To be successful in this role, you will need:

  • A current nursing (RN) license with a Bachelor's Degree in Nursing, or a Bachelor's degree in HIM with current certification (RHIA, RHIT, and/or CCS).
  • 2 years of experience in acute care, healthcare administration, or a related field.
  • CCDS certification within one year of hire.
  • Excellent communication and interpersonal skills.
About NYU Langone Health

NYU Langone Health is a world-class, patient-centered, integrated academic medical center. We are committed to providing exceptional care, advancing medical knowledge, and training the next generation of healthcare professionals. Our team is dedicated to making a positive impact on the lives of our patients, families, and communities.



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