DOCUMENT IMPROVEMENT SPECIALIST

The Document Improvement Specialist will have full responsibility to audit patient accounts in conjunction with clinical documentation integrity, coding, quality, and risk management.  This individual will be responsible for reviewing clinical documentation and ensuring that it is accurate, complete, and reflects the level of care provided to the patient. They will also serve as a resource for healthcare providers to improve documentation practices, coding accuracy, and reimbursement.

Education/Skills/Knowledge:

Associates Degree required - Nursing, Healthcare Administration, or related field

5+ years of experience in clinical documentation review and/or coding in a hospital setting with 3+ years of auditing experience.

ACDIS Certification as Clinical Documentation Improvement (CCDS) or AHIMA Certification as Certified Documentation Integrity Practitioner (CDIP) required.

Current RN, LPN, or Physician Assistant license preferred. 

Certified Coding Specialist (CCS) preferred. 

Knowledge of clinical documentation guidelines and regulatory requirements. 

Proficiency ICD-10-CM and ICD-10-PCS.

Working knowledge of state and federal regulations regarding fraud and abuse laws.

Experience with electronic health records (EHR) and coding software systems.

Applies knowledge of quality measures including HAC, HARM, HCC, and Risk Adjustment methodologies to reviews ensuring appropriate data submission. 

Proficiency in PSI 90, mortality reviews, and readmission data. 

Ability to see the big picture of data, recognizing all aspects of coded data and the importance of how it uses, i.e. quality measures, risk adjustment, etc.   

Advanced knowledge of researching coding related issues. (i.e. coding clinics, coding guidelines, etc.) 

Keeps abreast of coding guidelines, HCC diagnoses, HAC lists, and reimbursement reporting requirements.  

Possesses ability to be confidential; demonstrates knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of sensitive information. 

Possesses a cooperative and positive attitude toward management and co-workers by responding politely and professionally and being a valued team player. 

Work collaboratively with physicians, nurses, and other healthcare providers to improve documentation practices and ensure accuracy of clinical documentation. 

Department: Revenue Cycle Bargaining Unit: Non Union Campus: YONKERS  Employment Status: Regular Full-Time Address: 100 Corporate Blvd, Yonkers
Shift: Day Scheduled Hours: 7:30 AM-4 PM Req ID: 216542 Salary Range/Pay Rate: $90,000.00 - $120,000.00    

For positions that have only a rate listed, the displayed rate is the hiring rate but could be subject to change based on shift differential, experience, education or other relevant factors.

To learn more about the “Montefiore Difference” – who we are at Montefiore and all that we have to offer our associates, please click here.  

Diversity, equity and inclusion are core values of Montefiore. We are committed to recruiting and creating an environment in which associates feel empowered to thrive and be their authentic selves through our inclusive culture. We welcome your interest and invite you to join us.

Montefiore is an equal employment opportunity employer. Montefiore will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law. 

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