Job Description

Department/Unit:

Clinical Documentation Improvement

Work Shift:

Day (United States of America)

Salary Range: $65,057.00 - $107,343.00

Utilizes clinical expertise to assess clinical documentation concurrently and retrospectively; contributes to improvement of the overall completeness and quality of the documentation/medical record; collaborates extensively with physicians and other health care providers so that the clinical documentation reflects accurately the complexity of patients care; provides ongoing education to all healthcare providers regarding the importance of accurate documentation; collaborates with the HIM and the Quality Management departments; exhibits extensive knowledge of clinical documentation requirements and DRG assignment; supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.

Essential Duties & Responsibilities, including but not limited to:

Contributes to the creation of a compassionate and caring environment for patients, families and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employees work is valuable and contributes to the success of the Mission. Demonstrates excellence in daily work. Actively participates in performance and quality improvement activities and works toward enhancing customer/patient satisfaction. Exhibits positive service excellence skills to patients, visitors and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays and changes. Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance. Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols, which address the needs of a diverse patient population and workforce. Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work on time, displaying a consciousness regarding costs, supplies and department finances. Demonstrates respect for individual differences of each person by acknowledging the essence of each person, appreciating and responding to unique, spiritual, personal and cultural backgrounds of patients, families and colleagues.

Education:

+ Bachelors degree in Nursing or health related degree is required

+ MD, DO, MBBS or foreign educated medical graduate with advanced clinical practice experience

Licensure, Certification & Registration:

+ Valid CDI Certification such as CDIP or CCDS preferred

+ Valid Coding certification such as CCA or CCS preferred

+ Current NYS RN license required for nurses

+ If foreign educated medical graduate, ECFMG certificate preferred

Experience:

+ Advanced clinical experience with extensive knowledge of complex disease processes and broad clinical practice experience in the inpatient and outpatient settings required

+ CDI experience preferred

+ At least 5 years adult acute care practice experience

+ Demonstrated effective, collegial communication with physicians, other providers, staff and leadership through direct discussion and written communications

Skills, Knowledge & Abilities:

+ Excellent interpersonal and analytical skills.

+ Must be able to function independently, interpret information, communicate with medical and clinical staff and both internal and external to the institution

+ Able to provide oral presentations both in person and virtually

+ Must be motivated, organized with excellent verbal, written communication skills, and conversant with adult professional learners.

+ Ability to work independently and as a member of a team utilizing critical thinking skills.

+ Demonstrated competence in data analysis and data interpretation.

+ Knowledge of ICD-10 codes and coding guidelines.

+ Ability to prioritize workflow and manage various initiatives.

+ Demonstrated quality improvement knowledge/skills with regard to workflow and productivity processes

+ Strong speaking and writing skills required

+ Excellent presentation skills required

+ Able to produce reports in Microsoft Office components, Word, Power Point, Excel, and Access data bases

+ Demonstrated effective facilitation skills

+ Good listening skills

+ Strong interpersonal communication skills with the ability to relate to all levels of education and organization positions

Thank you for your interest in Albany Medical Center!?

Albany Medical is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Medical Center, 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 Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

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