Req Number: 159972

Overview:

Join our dynamic team as we prioritize the significance of precise clinical documentation in the healthcare system! We are looking for a dedicated professional to enhance the accuracy of clinical records, ensuring that they accurately reflect patient conditions, the level of care provided, and support billing processes. This role is crucial in performing concurrent inpatient medical record reviews for Medicare, Medicaid, and various commercial payers, and involves collaboration with physicians to resolve any discrepancies in documentation.

Key Responsibilities:

• Facilitate and ensure the precision and integrity of clinical documentation within medical records.
• Work to confirm that clinical documentation effectively supports diagnosis coding and accurately represents the level of service provided.
• Engage with physicians on assigned patient units to clarify and enhance clinical documentation through ongoing reviews throughout each patient’s hospital stay.
• Promptly request needed clarifications from physicians on clinical documentation to confirm completeness and accuracy prior to patient discharge.
• Document the severity of illness and level of services rendered to patients accurately within records.
• Follow up diligently on clinical documentation improvement (CDI) queries to ensure thorough and precise documentation.
• Consult with physicians when necessary to clarify documentation requirements and provide timely guidance on coding queries.
• Exhibit a strong understanding of ICD-10 CM, ICD-10 PCS coding, MS-DRG, and APR methodologies to identify documentation opportunities and ensure compliance with regulatory standards.
• Conduct follow-up reviews to guarantee that clarifications are noted in patient charts properly.
• Reconcile reviewed cases to record any changes in patient status, treatments, and collaborate with providers to finalize diagnoses.
• Educate medical staff about key clinical documentation practices that can enhance the accuracy of medical records.
• Utilize CDI software for data input to track and analyze responses to queries and maintain necessary files for auditing results.
• Exercise independent judgment on significant matters while adhering to established procedures.
• Understand the overarching strategies and operational objectives of the department and organization.
• Receive general guidance on routine tasks and detailed instructions for new projects or responsibilities.
• Maintain customer service relations primarily within departmental interactions.
• Perform additional duties as necessary, with all listed responsibilities being key functions as per the Americans with Disabilities Act.

Qualifications:

• Graduate from an accredited School of Nursing is required.
• Must earn a Bachelor of Science in Nursing degree within five years of employment.
• A valid New York State Registered Professional Nurse license is essential, along with any required specialized certifications (such as CCEDS, CDIP, CCDS, or CCS).
• A minimum of 1-3 years of relevant experience is required.

Compensation Details:

The projected salary range for this role is competitive and set between $78,000 and $130,000 annually. This range is a good-faith estimate of potential base compensation for a successful candidate at the time of this job posting, which may be adjusted in the future based on various factors, including location, specialty, service line, relevant experience, education, credentials, and internal equity.

At Northwell Health, we are proud to uphold an equal employment opportunity policy, ensuring fair treatment for all applicants and employees regardless of their characteristics or backgrounds, in accordance with applicable laws.