Clinical Documentation Specialist - Surgical

Location
Stony Brook, NY
Posted
Feb 23, 2018
Institution Type
Four-Year Institution
Job Description

Clinical Documentation Specialist - Surgical-1800564

Position Summary


At Stony Brook Medicine, a Clinical Documentation Specialist (CDIS) - Surgical is responsible for the overall accuracy and the integrity of the medial record. The position facilitates the capture of accurate medical record documentation at the point of care through interaction with physicians, and other caregivers. The specialist advocates for appropriate patient classification relative to

the level of care provided and supports accuracy of information that will be used for measuring and reporting physician and hospital outcomes. The CDIS follows coding guidelines and hospital policies to ensure compliance with clinical documentation.



Duties of a TH Staff Associate/Clinical Documentation Specialist in the Revenue Integrity Department may include the following but are not limited to:

  • Improves the overall quality and completeness of concurrent inpatient documentation by performing initial and follow up reviews to facilitate appropriate reimbursement and compliance with performance measures.
  • Interacts and communicates with physician staff daily, clarifying documentation in the medical record through verbal, electronic and paper query. Providing follow up to ensure points of clarification have been recorded in the medical record.
  • Identifies appropriate principal diagnosis to establish a working DRG assignment and average length of stay. Maintain DRG worksheet to include abstraction of patient's clinical findings relevant to principal and secondary diagnosis and procedures.
  • Demonstrates knowledge of DRG payer issues, appropriate DRG assignment alternatives, clinical documentation requirements of core measures and improves the overall quality and completeness of the medical record.
  • Works in coordination with the Physician Advisor and Associate Director of CDI to develop and present physician and staff education on documentation, coding, quality and regulatory performance.
  • Works in coordination with coding specialists to ensure appropriate reimbursement based on clinical level of service.
  • All other duties as assigned by departmental management.

Qualifications


Required Qualifications: Current NYS RN License with Bachelor’s Degree in a health related field or advanced licensure of Nurse Practitioner or Physician Assistant. Minimum of five years of clinical experience.


Must include SURGICAL experience which can include but is not limited to:

  • Inpatient surgical experience
  • Outpatient/ Ambulatory surgery experience
  • Administrative surgical experience
  • Case Management surgical experience


Preferred Qualifications:

  • Surgical Intensive Care Unit experience
  • CDl experience in an Acute Care hospital
  • CCDS (Certified Clinical Documentation Specialist) credential
  • CCS (Certified Coding Specialist) credential


Special Notes: Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.


All Hospital positions are subject to changes in pass days and shifts as necessary. This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.


The selected candidate must successfully clear a background investigation. Prior to start date, the selected candidate must meet the following requirements: Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services (The hiring department will be responsible for any fee incurred for examination), submit (3) written references, and provide a copy of any required New York State license(s)/certificate(s). Please be advised that failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.


The best ideas in medicine start with the best people. At Stony Brook Medicine, our highest calling is to put the power of ideas to work in our patients’ lives. Stony Brook Medicine integrates and elevates all of our health-related initiatives: education, research and patient care. Stony Brook Medicine is Long Island’s premier academic medical center. With 603 beds, we serve as the region’s only tertiary care center and Level 1 Trauma Center, and are home to the Stony Brook Heart Institute, Stony Brook Cancer Center, Stony Brook Children’s Hospital, Stony Brook Neurosciences Institute, and Stony Brook Digestive Disorders Institute. We also encompass Suffolk County’s only Level 4 Regional Perinatal Center, state-designated AIDS Center, state-designated Comprehensive Psychiatric Emergency Program, state-designated Burn Center, the Christopher Pendergast ALS Center of Excellence, and Kidney Transplant Center. It is home of the nation’s first Pediatric Multiple Sclerosis Center.


Stony Brook University is an Affirmative Action/Equal Opportunity employer. We are committed to the creation of a diverse and inclusive campus climate. We encourage protected veterans, individuals with disabilities, women and minorities to apply.


This function/position has been designated as “essential.” This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.

Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor’s Office of Employee Relations at (518) 474-6988 or via email at info@goer.ny.gov.


IF YOU NEED A DISABILITY-RELATED ACCOMMODATION, PLEASE CALL THE UNIVERSITY HUMAN RESOURCE SERVICES DEPARTMENT AT (631) 632-6161 OR THE UNIVERSITY HOSPITAL HUMAN RESOURCES DEPARTMENT AT (631) 444-4700. IN ACCORDANCE WITH THE TITLE II CRIME AWARENESS AND SECURITY ACT, A COPY OF OUR CRIME STATISTICS IS AVAILABLE UPON REQUEST BY CALLING (631) 632-6350. IT CAN ALSO BE VIEWED ON-LINE AT THE UNIVERSITY POLICE WEBSITE AT http://www.stonybrook.edu/police



Official Job Title: TH Staff Associate
Job Field: Administrative & Professional (non-Clinical)
Primary Location: US-NY-Stony Brook
Department/Hiring Area: Revenue Integrity-Stony Brook University Hospital
Schedule: Full-time Day Shift 8:00AM - 4:00PM (may vary)Revenue Integrity-Stony Brook University Hospital
Posting Start Date: Feb 22, 2018
Posting End Date: Mar 24, 2018, 10:59:00 PM
Salary: Commensurate with experience
Salary Grade: SL4

PI101324964

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