Clinical Documentation Specialist

2 weeks ago


Lake Success, United States Northwell Health Full time
Job Summary

We are seeking a skilled Clinical Documentation Specialist to join our team at Northwell Health. As a key member of our healthcare team, you will play a vital role in ensuring the accuracy and integrity of clinical documentation for all patients.

In this dynamic role, you will be responsible for facilitating and obtaining appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided. Your expertise will be utilized to generate queries and have follow-up discussions with physicians for clarification of ambiguous or conflicting documentation.

You will work closely with physicians on assigned patient care units to clarify clinical documentation in the patient's medical record through a concurrent review process throughout the patient's inpatient stay. This is an excellent opportunity to apply your knowledge of ICD-10 CM and ICD-10 PCS coding, MS-DRG and APR NY and APR National grouper logic, documentation opportunities, clinical documentation requirements, and compliance to regulatory and facility policies and procedures.



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