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NYU Langone Health is a world-class, patient-centered, integrated academic medical center, known for its excellence in clinical care, research, and education. It comprises more than 200 locations throughout the New York area, including five inpatient locations, a children's hospital, three emergency rooms and a level 1 trauma center. Also part of NYU Langone Health is the Laura and Isaac Perlmutter Cancer Center, a National Cancer Institute designated cancer center, and NYU School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. For more information, go to nyulangone.org, and interact with us on Facebook, Twitter, YouTube and Instagram.

Position Summary:
We have an exciting opportunity to join our team as a Clinical Doc Specialist-HIM.

In this role, the successful candidate is responsible for the facilitation of improvement in the overall quality, completeness, and accuracy of medical record documentation, by thorough chart review and extensive interaction with physicians, nurses, other patient care providers and HIM coding staff.

Job Responsibilities:

  • Assists with special projects as needed and perform related duties as assigned.
  • Provides feedback to physicians and other staff on the results of auditing and monitoring activities
  • Implements and participates in corrective action plans to ensure resolution of problem areas which are identified during internal or external auditing.
  • Serves as a resource to staff and physicians to obtain information or clarification on accurate and ethical reporting and documentation standards, guidelines and regulatory requirements
  • Participates in educational training programs regarding appropriate documentation required for complete and accurate coding and reporting.
  • Identifies opportunities for physician/practitioner education to improve documentation for severity of illness.
  • Coordinate final reporting of diagnoses with coding staff, providing clinical recommendations as needed.
  • Provides post discharge/pre-bill retrospective review of records in HIM for potential documentation improvement by applying concurrent standards of review and query processes.
  • Facilitates continuity of patient care by assisting in the screening process, making referrals and interacting with physicians and case management staff.
  • Reviews documentation for core measure standards and confers with the health care team to facilitate appropriateness of documentation.
  • Confers with coding staff and HIM leadership to review assignment of appropriate DRG and completeness of supporting documentation as needed.
  • Re-reviews medical records at discharge to identify responses to queries and validate documentation adequacy.
  • Logs all concurrent queries.
  • Maintains worksheets on all concurrent reviews
  • Consults a physician advisor when indicated by review results and/or query response
  • Interprets clinical information in the medical record (i.e. medications, vital signs, surgical outcomes, laboratory/diagnostic test results) to identify potential diagnoses.
  • Queries physicians for clarification and specificity of documentation in accordance with hospital policies and the AHIMA practice brief (Managing an Effective Query Process).
  • Applies knowledge of DRG documentation requirements to accomplish appropriate coding and to reflect accurate case mix index and clinical outcomes for the hospital.
  • Performs admission/continued stay review on assigned charts to include assignment of DRG, based on coding guidelines/regulations (i.e. AHA Coding Clinic, CMS, AHIMA), identification of complications and/or co-morbid conditions, and specific co-existing conditions.
  • Uses software and CDI tools to conduct concurrent review to evaluate documentation adequacy

Minimum Qualifications:
To qualify you must have a RN, Coder, or Healthcare Professional
Bachelors degree required (for all hires after 2008)
Five years recent experience in adult medical/surgical acute care, utilization review, case management, or clinical documentation improvement.
NY State Licensed RN or PA
CCDS preferred

Coder:
Bachelors degree required (for all hires after 2008)
Three years recent experience as an inpatient coder.
Certificate from accredited coding school.
CCS, HRIT RHIA or CCDS preferred

Healthcare Professional:
Graduate education leading to MD, DO, or equivalent degree required
2-3 years experience in acute care, health care administration or commensurate experience
Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents.

NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.
If you wish to view NYU Langone Health's EEO policies, please click here. Please click here to view the Federal "EEO is the law" poster or visit https://www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm for more information. To view the Pay Transparency Notice, please click here.

Position Summary:
Responsible for the facilitation of improvement in the overall quality, completeness, and accuracy of medical record documentation, by thorough chart review and extensive interaction with physicians, nurses, other patient care providers and HIM coding staff.

Minimum Qualifications:
RN, Coder, or Healthcare Professional
Bachelors degree required (for all hires after 2008)
Five years recent experience in adult medical/surgical acute care, utilization review, case management, or clinical documentation improvement.
NY State Licensed RN or PA
CCDS preferred
Coder:
Bachelors degree required (for all hires after 2008)
Three years recent experience as an inpatient coder.
Certificate from accredited coding school.
CCS, HRIT RHIA or CCDS preferred
Healthcare Professional:
Graduate education leading to MD, DO, or equivalent degree required
2-3 years experience in acute care, health care administration or commensurate experience
Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement



* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.


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