Clinical Documentation Specialist

Job Requisition: REQ2672 Employment Type: Full-Time Shift: Days Hours Per Week: 40 hours per week On-Site Required Hiring range: 35.18 - 45.73 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.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.Complexity of Work: Within scope of job, requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment.Must be able to work in a stressful environment. Must be able to speak, read, write and follow instructions in English.Personal Protective Equipment: Follows Standard Precautions using personal protective equipment as required.Education: Associate's degree, or Bachelor's degree required.