Clin Doc Spec

Position Overview

Department/Unit: AMHS - Clinical Documentation Integrity.

Work Shift:

Day (United States of America). Salary Range: $77,075.00 - $. Hybrid position requiring residency in New York State.

• Utilize clinical expertise to assess clinical documentation concurrently and retrospectively.
• Contribute to improvement of the overall completeness and quality of the documentation/medical record.
• Collaborate extensively with physicians and other health care providers to ensure clinical documentation accurately reflects the complexity of patient care.
• Provide ongoing education to all healthcare providers regarding the importance of accurate documentation.
• Collaborate with HIM and the Quality Management departments.
• Demonstrate extensive knowledge of clinical documentation requirements and DRG assignment.
• Support timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.

• Education:
  
  Bachelor's degree in Nursing or related health field required. MD, DO, MBBS, or foreign-educated medical graduate with advanced clinical practice experience acceptable.
• Licensure, Certification & Registration:
  Valid CDI Certification (e.g., CDIP or CCDS) preferred. Valid coding certification (CCA or CCS) preferred. Current NYS RN license required for nurses. Foreign-educated medical graduate: ECFMG certificate preferred.
• Experience:
  
  At least 5 years of adult acute care practice and broad clinical practice in inpatient and outpatient settings. CDI experience preferred.

• Excellent interpersonal, analytical, and communication skills.
• Ability to work independently and as part of a team, using critical thinking skills.
• Proficient in data analysis and interpretation.
• Knowledge of ICD-10 coding guidelines.
• Excellent oral and written presentation and facilitation skills.
• Proficiency with Microsoft Office applications (Word, PowerPoint, Excel, Access).
• Strong listening and interpersonal communication skills.

This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties.

Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

• Excellent health care coverage with no copay at Albany Medical Center providers.
• A wide array of services and programs to support emotional, physical, and mental wellbeing.
• Albany Med Health System is an equal opportunity employer.