Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
Dept Name: Clinical Documentation REQ # 2488750
Job Title: Clinical Documentation QI Specialist II
Roles & Responsibilities:
The Clinical Documentation Quality
Improvement Specialist II is responsible for improving the overall quality and
completeness of clinical documentation; facilitates modifications to clinical
documentation through extensive interaction with physicians, nursing staff,
other patient caregivers, and medical records coding staff to ensure that
documentation reflects complete and accurate level of service rendered to
1. Experienced CDQI with minimum 2-4 years recent experience in CDI role
2.To meet quality and quantity expectations within 6 months of employment.
3. Quality review: ≥ 93%;
4. Quantity: 12-15 Initial Chart reviews, >25% Query Rate.
5. Attains Clinical Documentation Specialist certification through ACDIS or AHIMA
6. The CDI specialist II also assists leadership in utilizing expertise in CDI and data analysis in evaluating CDI accuracy, standardizing review findings and reporting out results.
7. Works effectively and efficiently, able to work on several things at once while maintaining expected productivity outcomes. Meets established productivity goals without sacrificing quality.
8.Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records.
9. Facilitates modification of clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer under Medicare.
10. Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.
11. Ability to write queries that are concise and easily understood by the queried provider, in order to garner additional necessary documentation in the inpatient medical record
12. Timely reconciliation of all cases, to include accurate recording of DRG or SOI impact based on physician query, as well as physician response to all queries
13. Identify query opportunities, diagnoses not supported by clinical indicators, and function on par with other CDI team members.
14. Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team
15. Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payor regulations.
16. Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
17. Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.
18. Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data and clinical validation.
19. Performs other related duties.
HS diploma or GED required. Bachelor's degree preferred
At least 1-2 years of CCS, CDIP or CCDS or equivalent. CCA (Clinical Coding Analyst), CCS (Clinical Coding Specialist) or CCDS (Certified Clinical Documentation Specialist) preferred. Advanced knowledge of internet applications and #M encoder exp. Demonstrated knowledge of ICD-10 CM/PCS codes, DRG and CPT coding.
Strength Through Diversity
The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.
We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care.
Explore more about this opportunity and how you can help us write a new chapter in our story!
Who We Are
Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation. EOE Minorities/Women/Disabled/Veterans