BronxCare Health System
Full job description
Overview:
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.
Responsibilities:
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.
Qualifications:
Bachelors degree, required.
Current MD/MBBS.
CDI/Coding experience preferred, but not required.
To apply for this job please visit careers-bronxcare.icims.com.
