Northwell Health

Clinical Documentation Specialist (Part-Time, CDI Certified) - $15K Sign-on Bonus and Remote

2 months agoGarden City, NY

Job Description

Job Responsibilities

  • Facilitates clarification of clinical documentation ensuring accuracy and integrity in the medical record.
  • Facilitates appropriate clinical documentation to support diagnosis coding and ensure the severity of the services are recorded.
  • Works with Medical Providers to clarify clinical documentation in the patient's medical record through a concurrent review process throughout the patient's inpatient stay.
  • Requests clarification of clinical documentation from the Provider(s) on a concurrent basis, as needed, to ensure documentation is complete and accurate. Follows up on CDI queries as needed to ensure appropriate documentation is recorded in the medical record.
  • Interacts with Providers, as needed, to discuss and educate on clinical documentation requirements. Provides timely and accurate responses to clinical documentation and coding questions.
  • Demonstrates knowledge of ICD-10 CM and ICD-10 PCS coding, MS-DRG and APR NY and APR National grouper logic, and documentation opportunities.
  • Demonstrates knowledge of clinical documentation requirements and complies to regulatory and facility policies and procedures.
  • Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
  • Reconciles reviewed cases to update any changes in status, procedures/treatments, and confers with Providers to finalize diagnoses. Communicates findings of potential or missed diagnoses.
  • Inputs data timely and accurately in the CDI software to be able to track CDI review data and responses to queries.
  • Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here but considered related are not essential functions.
Job Qualifications
  • Preferred graduate from an accredited School of Nursing, current NYS license, reciprocity is accepted.
    • 3-5 years of acute hospital care experience, required
    • CCDS and CCS preferred
  • RHIA with minimum of 5 years inpatient coding/auditing/CDI experience and strong clinical knowledge or RHIT with minimum of 10 years of inpatient coding/auditing/CDI experience and strong clinical knowledge.
    • CCS is required
    • CCDS preferred
  • PC Skills: Demonstrates proficiency in Microsoft Office, and Teams, VPN access, navigating a variety of EHRs, and ability to problem solve computer connectivity issues.
  • Communication Skills: Communicates clearly, proactively, and concisely with all key stakeholders. Excellent written and verbal communication skills. Writes clear, accurate, and compliant queries according to the AHIMA practice brief and the Organization's query policy.
  • Critical Thinking: Actively and skillfully conceptualizes, applies, analyzes, synthesizes, and evaluates information gathered from a thorough and complete chart review.
  • Adaptability: Maintains effectiveness when experiencing changes in work tasks or the work environment; adapts to change in environment and/or circumstances with a positive outlook and adjusts effectively to work within new work structures, processes, requirements, or cultures.
  • Initiative: Proactive and self-directed. Shows initiative and responsibility in taking the necessary steps towards problem resolution. Is self-sufficient and does not need to rely on others to complete a job.

Job Information
  • Location: Remote and On-site positions available
  • Position Title: Clinical Documentation Specialist
  • Company Name: Northwell Health
  • Org Type: Hospital/Health System
  • Job Function: CDI/Clinical Documentation Improvement
  • Job Type: Full-Time & Part-Time
  • Job Duration: Indefinite
  • Min Education: Bachelor's Degree preferred
  • $15,000 sign on bonus for full-time or $7,500 sign on bonus for part-time

Client-provided location(s): Lynbrook, NY 11563, USA
Job ID: Northwell-12397108