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NYU School of Medicine Documentation Specialist in Brooklyn, New York

NYU Langone Hospital - Brooklyn is a full-service teaching hospital and Level I trauma center located in Sunset Park, Brooklyn. The hospital is central to a comprehensive network of affiliated ambulatory and outpatient practices, and serves as NYU Langone Health’s anchor for healthcare access, growth, and delivery in the entire borough. Learn more about NYU Langone Hospital - Brooklyn.
Position Summary:
We have an exciting opportunity to join our team as a Documentation Specialist.
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:
Uses software and CDI tools to conduct concurrent review to evaluate documentation adequacy
Performs concurrant stay review on assigned charts to include assignment of DRG based on coding guildelines/regulations Ii.e. AHA Coding Clinic, CMS, AHIMA) identification of complications and/or co-morbid conditions, and specific co-existing conditions.
Applies knowledge of DRG documentation requirements to accomplish appropriate coding and to reflect accurate case mix index and clinical outcomes for the hospital
Queries physicians for clarification and specificity of documentation in accordance with hospital
policies and the AHIMA practice brief (Managing an Effective Query Process
Interprets clinical information in the medical record (i.e. medications, vital signs, surgical outcomes,
laboratory/diagnostic test results) to identify P0tential diagnoses
Consults a physician advisor when indicated by review results and/or query response
Maintains worksheets on all concurrent reviews
Logs all concurrent queries
Re-reviews medical records at discharge to identify responses to queries and validate documentation adequacy.
Confers with coding staff and HIM leadership to review assignment of appropriate DRG and
completeness of supporting documentation as needed
Provides post.dischargelpre.bill retrospective review of reoords in HIM for potential”d’ocumentation -
improvement by applying concurrent standards of review and query processes
Coordinate final reporting of diagnoses with coding staff, providing clinical recommendations as
needed.
Identifies opportunities for physician/practitioner education to improve documentation for severity of illness. Risk of mortality and quality indicators.
Participates in educational training programs regarding approoriate documentation required for complete and accurate coding and reporting.
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 corrective action plans to ensure resolution of problem areas which
are identified during internal or external auditing
Provides feedback to physicians and other staff on the results of auditing and monitoring activities.
Assists with special projects as needed and perform related duties as assigned
Minimum Qualifications:
-Qualified candidates are practicing Registered Nurses, Physician Assistants, Coders, or other Healthcare professionals.
-Bachelor’s degree required (for all hires after 2008).
-Experience desired: 5 years recent experience in adult med/surg acute care, utilization review, case management, or clinical documentation improvement.
-NY State Licensed RN or PA
-CCDS certification preferred
-Coder requirements:Three years recent experience as an inpatient coder. Certificate from accredited coding school, CCS, HRIT RHIA or CCDS preferred
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.
Preferred Qualifications:
Qualifications: All
Working knowledge of ICD-9-CM coding principles and guidelines or willingness to obtain.
Working knowledge of federal, state, and payor-specific regulations and policies pertaining to
documentation, coding, and reimbursement or willingness to obtain.
Strong interpersonal and leadership skills.
Excellent written and oral communication skills.
Excellent critical thinking and multi-tasking skills.
Willingness to devote the time required to complete assigned tasks.
Ability to work on active nursing units interfacing with physicians and interdisciplinary team required.
Application of coding clinic guidelines and knowledge of DRG’s.
Clinical knowledge and knowledge of coded data for documentation requirements to improve overall patient quality,
capture severity, acuity and risk of mortality.
Qualified candidates must be able to effectively communicate with all levels of the organization.
NYU Langone Hospital - Brooklyn 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 Hospital-Brooklyn 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 Hospital- Brooklyn’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.

NYU Lutheran Medical Center 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.

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