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Clinical Documentation Specialist
full-time•New York
About this role
Overview
Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. Knowledge of age-specific patient needs and the elements of disease processes and related procedures. Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
Responsibilities
Provides concurrent and retrospective review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Key responsibility will be to review the chart for information not currently in the chart but that is indicated by clinical indicators in the record. Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.
Qualifications
MD; MBBS or any equivalent degree, policy requirement. Bachelor's degree require.Current MD/MBBS CDI/Coding experience preferred, but not required
What you'll do
- The Clinical Documentation Specialist provides concurrent and retrospective reviews of clinical documentation in medical records. They identify missing or understated diagnoses and query medical staff to ensure accurate documentation.
About BronxCare Health System
BronxCare is the largest voluntary, not-for-profit health and teaching hospital system serving the South and Central Bronx, with 859 beds and more than 4,500 employees. Its two main hospital divisions, comprehensive psychiatric and chemical dependency programs, long-term care facility, and extensive outpatient network of 39 practices are providing the wide range of services needed by the community. BronxCare is now among the largest providers of outpatient services in New York City, with close to 750,000 visits annually. Its ER is among the largest in the nation with 127,000 visits annually.
In 2023, BronxCare received full accreditation from the Joint Commission, the leading accrediting authority for hospitals in the nation. Its medical school affiliation with the Icahn School of Medicine at Mount Sinai and clinical collaboration with the Mount Sinai Health System, as well as 16 accredited residency and fellowship programs, are strong indicators of excellence. BronxCare’s outpatient practices are also certified as a Level Three Patient-Centered Medical Home (the highest designation) by the National Committee for Quality Assurance (NCQA).
As an engine for positive change, BronxCare has infused more than $400 million into the Bronx economy, including a new Pediatric Specialty Center and Ophthalmology Practice, among numerous other capital projects. A new 33-bed Medical-Surgical Unit at the Concourse Hospital Division and 20-bed Adult Psychiatric Unit at the Fulton Hospital Division will increase inpatient capacity to 912 beds, further reinforcing BronxCare’s ability to address the significant needs of the Bronx community.
BronxCare is also modernizing its Inpatient Maternity and Labor and Delivery Units, as well as its Women’s Health Center and Neurology Suite, to improve the patient experience. Additionally, BronxCare’s Dr. Martin Luther King, Jr. Health Center Practice at 174th Street will be opening.
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Frequently Asked Questions
What does a Clinical Documentation Specialist do at BronxCare Health System?
As a Clinical Documentation Specialist at BronxCare Health System, you will: the Clinical Documentation Specialist provides concurrent and retrospective reviews of clinical documentation in medical records. They identify missing or understated diagnoses and query medical staff to ensure accurate documentation..
Is the Clinical Documentation Specialist position at BronxCare Health System remote?
The Clinical Documentation Specialist position at BronxCare Health System is based in New York, United States. Contact the company through Clera for specific work arrangement details.
How do I apply for the Clinical Documentation Specialist position at BronxCare Health System?
You can apply for the Clinical Documentation Specialist position at BronxCare Health Systemdirectly through Clera. Click the "Apply Now" button above to start your application. Clera's AI-powered platform will help match your profile with this opportunity and guide you through the application process.