Location: Albany,NY, USA
Department/Unit:
Clinical Documentation Improvement
Work Shift:
Day (United States of America)
Salary Range: $65,057.00 - $107,343.00
Reviews clinical documentation and assesses need for documentation clarification. If needed, places queries in compliance with the AHIMA Query Practice Briefs and Internal policies. Demonstrates familiarity with DRG assignment, ICD-10-CM Official Coding Guidelines, IPPS and CMS guidelines. Must have strong oral and written communication skills. Demonstrates professional responsibility and fosters teamwork. Seeks continuous self-improvement.
Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of patient care. Collaborates extensively with physicians, nursing staff and other healthcare providers, and with medical coding staff to improve quality and completeness of documentation of care provided and coded. Collaborates with Quality management so that the facility Quality scores are accurate.
Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.
Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. Understands, interprets, and uses data to provide education.
Education:
+ Bachelor's degree in Nursing or health related degree is required
+ MD, DO, MBBS or foreign educated medical graduate with advanced clinical practice experience
Licensure, Certification & Registration:
+ Valid CDI Certification such as CDIP or CCDS preferred
+ Valid Coding certification such as CCA or CCS preferred
+ Current NYS RN license required for nurses
+ If foreign educated medical graduate, ECFMG certificate preferred
Experience:
+ Advanced clinical experience with extensive knowledge of complex disease processes and broad clinical practice experience in the inpatient and outpatient settings required
+ CDI experience preferred
+ At least 5 years adult acute care practice experience
+ Demonstrated effective, collegial communication with physicians, other providers, staff and leadership through direct discussion and written communications
Skills, Knowledge & Abilities:
+ Excellent interpersonal and analytical skills.
+ Must be able to function independently, interpret information, communicate with medical and clinical staff and both internal and external to the institution
+ Able to provide oral presentations both in person and virtually
+ Must be motivated, organized with excellent verbal, written communication skills, and conversant with adult professional learners.
+ Ability to work independently and as a member of a team utilizing critical thinking skills.
+ Demonstrated competence in data analysis and data interpretation.
+ Knowledge of ICD-10 codes and coding guidelines.
+ Ability to prioritize workflow and manage various initiatives.
+ Demonstrated quality improvement knowledge/skills with regard to workflow and productivity processes
+ Strong speaking and writing skills required
+ Excellent presentation skills required
+ Able to produce reports in Microsoft Office components, Word, Power Point, Excel, and Access data bases
+ Demonstrated effective facilitation skills
+ Good listening skills
+ Strong interpersonal communication skills with the ability to relate to all levels of education and organization positions
Thank you for your interest in Albany Medical Center!?
Albany Medical is an equal opportunity employer.
This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:
Access to information is based on a need to know and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.