Clinical Documentation Speclst

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.

Establish and maintain positive relationships with patients, visitors and
other employees. Interacts professionally, courteously, and
appropriately with patients, visitors, and other employees. Behave in a
manner consistent with maintaining and furthering a positive public
perception of BronxCare Health System and its employees.

Contribute to and participate in the Performance/Quality Improvement
activities of the assigned department. Contribution and participation
includes data collection, analysis, implementation of and compliance with
corrective/improvement activities, membership on CQI teams, consistent
adherence to established performance standards and: adherence to the
specific rules and regulations of the BronxCare Health System’s Safety &
Security Policies; Risk Management: Incident and Occurrence Reporting;
Infection Control Policies and Procedures; Patient and Customer
Service.

Coordinates and maintains all elements of the Clinical Documentation
Improvement Program in order to meet the goals and objectives of the
organization and its stakeholders

Meet CDI program objectives, goals, and balance scorecard metrics.

Ensures timely, accurate, and complete documentation of clinical
information used for measuring and reporting physician and hospital
outcomes.

Ensure effective communications with key stakeholders.

Analyzes data, creates reports to meet desired outcomes.

Identifies trends and opportunities for improvement in clinical
documentation

Meets program quality and productivity guidelines and standards.

Collaborates with coding professionals to fully support the needs of
clinical code assignment, communicates proficiently with coding
professionals to resolve identified discrepancies.

Work effectively with CDI team members to accomplish departmental
goals.

Demonstrates continued advancement in professional growth.

Bachelor’s

MD; MBBS or any equivalent degree

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.