Clinical Documentation Quality Improvement Coordinator-Quality Dept- FT Days Remote

The MSHS Clinical Documentation Quality Coordinator supports multiple acute care hospitals within the systems department for Clinical Documentation Quality Improvement (CDQI).

The Quality Coordinator is responsible for performing quality reviews on medical records to validate ICD -10 CM/PCS codes, DRG appropriateness, missed secondary diagnoses and procedures, and ensure compliance and accuracy of the MS-DRG and APR DRG throughout the MS Health System. Also, provides clinical documentation and coding education to Clinical Documentation Improvement (CDI) specialists, medical staff, midlevel providers and others. Remains accessible as a subject matter expert for MSHS regarding documentation, reimbursement and data interpretation as it relates to inpatient records. The Clinical Documentation Quality Coordinator conducts the quality review of inpatient CDI cases, queries, assigned codes and working DRG and participates in process improvement activities based on audit results and hospital or institute performance improvement projects impacted by documentation.

1.Perform
reviews of inpatient records to:

a.Evaluate
documentation to assign the principal diagnosis, pertinent secondary diagnoses,
and procedures for accurate and optimal DRG assignment;

b.Evaluate
appropriateness of documentation to support quality standards including PSIs,
HACs ;

c.Identify
missed secondary diagnoses and procedures;

d.Query
clinicians to achieve improved clinical documentation and accurate coding for
optimal allowable reimbursement;

e.Perform
DRG reconciliation and inform HIM of any recommended coding changes.

2.Analyze
reports and identifies trends and statistical significance in coding
opportunities as well as CDI opportunities that will assist in the
organizational process of documentation improvement.

3.Work
closely with the CDI, HIM and Quality team to provide feedback ensuring coding
consistency and accuracy meeting the requirements of: ICD-10 CM/PCS, UHDDS and
sequencing guidelines, Federal and State regulations, American Hospital
Association Coding Guidelines and Coding Clinic.

4.Educate
and mentor new employees through the on-boarding process. Trains CDI staff on
initial CDI review and query process and provide on-going education related to
new topics in CDI, coding and reimbursement.

5.Provide
feedback to HIM management staff and CDI leadership regarding opportunities for
documentation improvement and participates with the planning and development of
educational programs directed towards improving documentation.

6.Develop
and maintains compliant query templates as needed due to annual changes in the
Inpatient Prospective Payment System (IPPS) and AHA Official Coding Guidelines
and Coding Clinics.

7.Generate
MSHS CDI policies and guidelines in accordance with AHIMA Practice Briefs,
Official Coding Guidelines, ACDIS standards and Coding Clinic.

8.Collaborate
with the CDI Manager in the analysis of CDIS reports and other statistical
reviews.

9.Assist
with the analysis of PSIs and HACs to ensure that the coding assignment was
properly assigned based upon review of the medical documentation and
application of coding guidelines.

10.Maintain confidentiality of
information acquired pertaining to patients, physicians, associates, and
visitors to the Hospital. Discusses patient and hospital information only among
appropriate personnel in private places.

11.Assumes responsibility for
performance of job duties in the safest possible manner, to assure personal
safety and that of co-workers, and to report all preventable hazards and unsafe
practices immediately to management.

12.Responsible for remaining
current with the latest healthcare technology and coding advice through reading
available coding literature, attendance of seminars and in-services, internet
research and other educational resources for inpatient and outpatient
reimbursement and coding.

13.Participates in education
programs to maintain up to date coding skills.

14.Consistently meets
established productivity targets for work assignments.

15.Participates in staff and
management meetings as they relate to HIM and CDI initiatives.

16.Other duties as assigned

• Bachelors Degree, minimum (preferred: Nursing or Information Systems or related)
• Registered Health Information Administrator or Registered Health Information Technician or equivalent experience preferred
• 5 years of related experience (greater preferred), working in acute care hospital or similar setting
• Certified Coding Specialist Certification (CCS, CCS-P) required

Compensation Statement

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $96,461.00 - $144,692.00 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

Non-Bargaining Unit, 331 - Clinical Document Mgnt - MSH, Mount Sinai Hospital