Clinical Doc Spclst, L 1 00000415 (Q)

Queens Hospital Center is making good on its promise to the people of southeastern and central Queens to maximize both patient convenience and positive clinical outcomes. Residents of Queens can count on the delivery of quality medical care right in their own borough. In 2002 the hospital opened a state-of-the-art, 261-bed facility that includes the Queens Cancer Center, the first comprehensive cancer treatment center in the borough.

1.Facilitates improvement in the overall quality, completeness, accuracy, specificity and timeliness ofphysician clinical record documentation through extensive medical record review, query process,and effective communication with appropriate clinical and coding staff, and by utilizing computerprograms and systems.

2.Obtains appropriate physician documentation for clinical conditions or procedures through extensiveon-going interaction with physicians, other patient caregivers, and medical records coding staff toensure the clinical documentation properly captures information describing patients’ acuity, severityof illness, and risk of mortality. Reflects the level of service delivered to patients is appropriate,complete, and accurate and supports appropriate reimbursement for the level of service rendered toall patients.

3.Completes concurrent and retrospective reviews of patient records for a specified patient populationto evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, post-admission complications and procedures for accurate Diagnosis-Related Group (DRG) assignmentand Case Mix Index (CMI), risk of mortality, and severity of illness.

4.Queries physicians for incomplete, inconsistent, unclear or conflicting health record documentationto clarify and resolve conflicting information in patient’s medical record prior to patient’s discharge;maintains a record of review and query activities and other appropriate records.

5. Provides feedback and completes follow-up review of patient medical record, to ensure points of clarification have been addressed and recorded in the patient’s chart, and to assign a working/updated or final DRG upon patient discharge and before final coding and quality reporting submissions, as necessary.

6. Identifies and reports areas of weakness that may impact financial opportunities, and works with Finance or other appropriate staff in resolution of problems.

7. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

8. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.

9. Assists in the orientation and training of new staff members, and provides continual guidance and mentoring, as required.

10. Educates providers on proper clinical documentation and coding guidelines and practices, and compliance and reimbursement issues on an ongoing basis. Advises on the impact of provider documentation on accurate reporting of a patient’s clinical information and reimbursement.

11. Attends and/or participates in staff, departmental and interdisciplinary meetings, LEAN efficiency/ process improvement events, training and quality assurance/performance improvement (QA/PI) activities.

12. Performs other related work, as assigned.

1. Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED); and Bachelor of Science in Nursing degree from an accredited college or university; and four (4) years of acute care experience; or

2. Valid New York State license and current registration to practice as a Nurse Practitioner (NP) issued by the NYSED; and two (2) years of experience, as described in "1" above; or

3. Valid New York State license and current registration to practice as a Physician Assistant (PA) issued by the NYSED; and two (2) years of experience, as described in "1" above; or

4. Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience; or

5. Successful completion of education that leads to a medical degree; and two (2) years of experience, as described in "4" above.

Please be advised that proof of Covid-19 vaccination is required prior to hire.

If you wish to apply for this position, please apply online at employment.nychhc.org.