Coordinates the Clinical Documentation Improvement Program, ensuring accurate and complete medical records that reflect patient acuity and support quality reporting, regulatory compliance, and reimbursement. Collaborates with physicians, coding professionals, CDI staff, and administrative stakeholders; analyzes documentation data, prepares reports, identifies improvement opportunities, resolves discrepancies, and meets program quality and productivity goals.
Overview
The Clinical Documentation Specialist (CDS) at BronxCare Health System plays a critical role inensuring the accuracy, completeness, and integrity of patient medical records. This position serves as akey liaison between clinical staff, coding professionals, and administrative teams to support highqualitydocumentation that reflects the severity of illness, risk of mortality, and complexity of caredelivered. The CDS contributes directly to improved patient outcomes, regulatory compliance, andappropriate reimbursement.
Responsibilities- Establish and maintain positive relationships with patients, visitors and other employees. Interactsprofessionally, courteously, and appropriately with patients, visitors, and other employees. Behave in amanner consistent with maintaining and furthering a positive public perception of BronxCare HealthSystem and its employees.
- Contribute to and participate in the Performance/Quality Improvement activities of the assigneddepartment. Contribution and participation includes data collection, analysis, implementation of andcompliance with corrective/improvement activities, membership on CQI teams, consistent adherenceto established performance standards and: adherence to the specific rules and regulations of theBronxCare Health System’s Safety & Security Policies; Risk Management: Incident and OccurrenceReporting; Infection Control Policies and Procedures; Patient and Customer Service.
- Coordinates and maintains all elements of the Clinical Documentation Improvement Program in orderto meet the goals and objectives of the organization and its stakeholders
- Meet CDI program objectives, goals, and balance scorecard metrics.
- Ensures timely, accurate, and complete documentation of clinical information used for measuring andreporting physician and hospital outcomes.
- Ensure effective communication with key stakeholders.
- Analyzes data, creates reports to meet desired outcomes.
- Identifies trends and opportunities for improvement in clinical documentation
- Meets program quality and productivity guidelines and standards.
- Collaborates with coding professionals to fully support the needs of clinical code assignment,communicates proficiently with coding professionals to resolve identified discrepancies.
- Work effectively with CDI team members to accomplish departmental goals.
Requirements:
- Foreign medical graduates or students from accredited program.
- MD
- Minimum of 1 year experience within a patient care enviroment.
- Basic computer skills including Microsoft Office
- Excellent verbal and written communication
- Must be able to work in a high-volume team enviroment
- Detailed oriented
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