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NewYork-Presbyterian

New York academic health system

Documentation Improvement Specialist - CDI

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours
Full-timeQueens, NY, USA$101k - $151k /yr

About the Job

Requirements

  • A bachelor's degree is required.
  • A background as a Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant, or trained Physician is required.
  • Five years of recent hospital experience and/or verifiable Documentation Improvement experience is required.
  • Experience in an Electronic Medical Record environment is required.

Responsibilities

  • Facilitate improvement of medical record documentation through concurrent and retrospective interventions, interactions with physicians, residents, and other licensed independent practitioners, and education for those clinicians.
  • Develop processes to identify documentation-improvement opportunities and intervene with attending physicians, residents, and physician extenders to improve medical record documentation.
  • Provide routine in-services to assigned clinical areas and Service Lines on regulatory documentation requirements, including feedback on the impact of clinician documentation on Service Line metrics.
  • Initiate and maintain records and databases to quantify documentation deficits, interventions, and their impact.
  • Conduct documentation-improvement interventions and ensure follow-through with recommendations.
  • Identify, investigate, and evaluate practices and processes to support continuous improvement in complete and accurate medical record documentation.
  • Participate in retrospective medical record reviews to collect data and resolve coding or documentation discrepancies.
  • Maintain knowledge of coding, billing, and documentation guidelines related to therapists’ clinical professions and third-party payer requirements.
  • Collaborate with the Manager of the Coding Unit as needed.
  • In collaboration with Coding Unit expertise, provide in-services to educate therapy staff and clinicians on correct billing, coding, and documentation through clear verbal or written communication.
  • Perform other job-related duties as assigned.

Desired Qualifications

  • Registered Nurse with two years of CDI experience.
  • Bachelor’s degree in Nursing.
  • A current Registered Nurse, Nurse Practitioner, or Physician Assistant license is highly preferred.

About the Company

NewYork-Presbyterian

New York academic health system

NewYork-Presbyterian is an academic health system serving New York City and surrounding communities. The system provides hospital, specialty, emergency, outpatient, research, and medical education services in affiliation with major medical schools. It serves patients, families, clinicians, students, researchers, and communities across New York. Its operating model centers on academic medicine integrated with hospitals, physician teams, research programs, technology, facilities, and centralized operations. Teams work across nursing, physicians, allied health, research, education, technology, facilities, and patient access. Teams support coordinated daily delivery.

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