Clinical Documentation Quality Improvement Specialist III-Mt Sinai Hospital- Remote

Job description

The Clinical Documentation Specialist III is a senior technician, responsible for improving the overall quality and completeness of clinical documentation, and proficient in all three grouper systems. Expert knowledge of ICD-10 CM/PCS and all current regulations. This individual 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 patients. Assumes responsibility for education of clinicians and project management as required. 1. Proficient in all (3) grouper systems, facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records. 2. 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. 3. Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical doc...