Clinical Documentation Specialist - HIM

NYU Langone Health is a fully integrated health system that consistently achieves the best patient outcomes through a rigorous focus on quality that has resulted in some of the lowest mortality rates in the nation. Vizient Inc. has ranked NYU Langone the No. 1 comprehensive academic medical center in the country for three years in a row, and U.S. News & World Report recently placed nine of its clinical specialties among the top five in the nation. NYU Langone offers a comprehensive range of medical services with one high standard of care across 6 inpatient locations, its Perlmutter Cancer Center, and over 320 outpatient locations in the New York area and Florida. With $14.2 billion in revenue this year, the system also includes two tuition-free medical schools, in Manhattan and on Long Island, and a vast research enterprise with over $1 billion in active awards from the National Institutes of Health.

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Position Summary:
We have an exciting opportunity to join our team as a Clinical Documentation Specialist - HIM.

In this role, the successful candidate as the Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.
Work closely with Coding to assist and/or coordinate in resolving documentation and coding issues. Participate in training to clinicians and provide ongoing support.
Ensure that documentation practices and processes comply with applicable regulatory guidelines and requirements. Participate in special projects when necessary.

Job Responsibilities:

• Manage other assignments and projects as assigned.
• Participate in the daily operations and activities of the CDI program to continually improve documentation.
• Utilize documentation tools on an ongoing basis.
• Regularly and effectively communicate with clinical staff, including physicians.
• Collaborate with Coding in an effort to maintain coding and documentation quality and compliance. Ensures that coding process and guidelines meet State and Federal requirements and standards.
• Works with the medical staff to continuously improve clinical documentation to facilitate accurate coding through the use of physician query when appropriate.
• Facilitates communication of various professionals to support organizational goals related to compliance, quality and coding.
• Assists in development of education for both clinical and non-clinical staff.
• Meets performance standards by setting goals and objectives, prioritizing work, and using available resources efficiently and effectively.
• Stays abreast of the latest developments, advancements, and trends in the field of documentation improvement and coding by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and maintaining certification or licensure. Integrates knowledge gained into current work practices.
• Participates in the training of new employees as needed.
• Ensures that work is completed accurately and according to schedule.

Minimum Qualifications:
To qualify you must have a Current nursing (RN) license with a Bachelor's Degree in Nursing, Bachelor's degree with current certification (RHIA, RHIT, and/or CCS), and/or graduate education leading to MD, DO, or equivalent degree required.
2 years of experience in acute care, health care administration or commensurate experience.
CCDS within one year of hire for all candidates. Experience with ICD-10 coding and DRG assignment.
Good oral and written communication skills. Excellent interpersonal skills.
Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement..

Required Licenses: Registered Nurse License-NYS, Reg Health Info Tech-RHIT, Reg Health Info Admin-RHIA

Preferred Qualifications:
HIM or related field experience. 2 years of clinical documentation improvement experience.

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU Langone Health 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.

At NYU Langone Health, we are committed to supporting our workforce and their loved ones with a comprehensive benefits and wellness package. Our offerings provide a robust support system for any stage of life, whether it's developing your career, starting a family, or saving for retirement. The support employees receive goes beyond a standard benefit offering, where employees have access to financial security benefits, a generous time-off program and employee resources groups for peer support. Additionally, all employees have access to our holistic employee wellness program, which focuses on seven key areas of well-being: physical, mental, nutritional, sleep, social, financial, and preventive care. The benefits and wellness package is designed to allow you to focus on what truly matters. Join us and experience the extensive resources and services designed to enhance your overall quality of life for you and your family.

NYU Langone Health is an equal opportunity employer and committed to inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration. We require applications to be completed online.

View NYU Langone Health's Equal Employment Opportunity (EEO) policy, Know Your Rights: Workplace discrimination is illegal.

NYU Langone Health provides a salary range to comply with the New York state Law on Salary Transparency in Job Advertisements. The salary range for the role is $97,589.95 - $137,191.60 Annually. Actual salaries depend on a variety of factors, including experience, specialty, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

To view the Pay Transparency Notice, please click here