At Stony Brook Medicine, a Clinical Documentation Specialist - Revenue Integrity is a valuable member of our team who is responsible for the overall accuracy and the integrity of the medial record. The Clinical Documentation Specialist - Revenue Integrity facilitates the capture of accurate medical record documentation at the point of care through interaction with physicians, and other caregivers. The Clinical Documentation Specialist - Revenue Integrity advocates for appropriate patient classification relative to the level of care provided and supports accuracy of information that will be used for measuring and reporting physician and hospital outcomes. The Clinical Documentation Specialist - Revenue Integrity follows coding guidelines and hospital policies to ensure compliance with clinical documentation.
Duties of a Clinical Documentation Specialist - Revenue Integrity may include but are not limited to the following:
Performs concurrent and retrospective medical record reviews evaluating for accurate and complete documentation in accordance with documentation improvement and coding guidelines.
Interacts and communicates with physicians and mid level providers when documentation needs are identified. Initiates verbal & electronic queries. Provides follow-up to ensure points of clarification have been recorded in the medical record.
Maintains records in database to include abstraction of patient's clinical findings relevant to principal and secondary diagnosis and procedures & establish productivity levels.
Identifies appropriate principal diagnosis to establish a working DRG assignment and average length of stay. Demonstrates knowledge of DRG payer issues and appropriate DRG assignment alternatives.
Works in coordination with the Physician Advisor and Associate Director of CDI to develop and present physician/ provider education regarding documentation, risk adjustment, coding, quality and regulatory performance.
Works in coordination with coding specialists to ensure appropriate reimbursement based on clinical level of service.
Other duties as assigned.
Current NYS Registered Nursing License with Health care related Bachelor degree, or advanced licensure as a Nurse Practitioner, or Physician Assistant.
At least 5 years of acute care clinical experience.
Special Notes : Resume/CV and cover letter should be included with the online application.
Posting Overview : This position will remain posted until filled or for a maximum of 90 days. An initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration, applications must be received before the initial review date (which is within two weeks of the posting date).
If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date. Please note, that if no candidate were identified and hired within 90 days from initial posting, the posting would close for review, and possibly reposted at a later date.
Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
All Hospital positions maybe subject to changes in pass days and shifts as necessary.
This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
This function/position maybe designated as "essential." This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.
Prior to start date, the selected candidate must meet the following requirements:
Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services*
Complete electronic reference check with a minimum of three (3) professional references.
Successfully complete a 5 panel drug screen*
Successfully complete a Background Check investigation.
Provide a copy of any required New York State license(s)/certificate(s).
Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.
*The hiring department will be responsible for any fee incurred for examination .
Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.
If you need a disability-related accommodation, please call the University Office of Equity and Access at (631)632-6280.
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Official Job Title: TH Staff Associate
Job Field: Administrative & Professional (non-Clinical)
Primary Location: US-NY-Stony Brook
Department/Hiring Area: Revenue Integrity-Stony Brook University Hospital
Schedule: Full-time Shift: Day Shift Shift Hours: 8-4:30 Pass Days: Sat, Sun
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