Department/Unit:

　　Clinical Documentation Improvement

　　Work Shift:

　　Day (United States of America)

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

　　Reviews clinical documentation and assesses need for documentation clarification. If needed, places queries in compliance with the AHIMA Query Practice Briefs and Internal policies. Demonstrates familiarity with DRG assignment, ICD-10-CM Official Coding Guidelines, IPPS and CMS guidelines. Must have strong oral and written communication skills. Demonstrates professional responsibility and fosters teamwork. Seeks continuous self-improvement.

　　Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of patient care. Collaborates extensively with physicians, nursing staff and other healthcare providers, and with medical coding staff to improve quality and completeness of documentation of care provided and coded. Collaborates with Quality management so that the facility Quality scores are accurate.

　　Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.

　　Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. Understands, interprets, and uses data to provide education.

　　Education:

　　Bachelor’s 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.

　　Albany Med is the centerpiece of medicine, research, and medical education in New York’s CapitalRegion and is the area's largest private employer with more than 10,000 employees.

　　Albany Med offers excellent career opportunities in a wide range of roles in both patient care andadministration. We value all our staff members and offer outstanding employee benefits including:

　　Excellent health care coverage (http://albanymedcareers.com/benefits/employee-health-%20benefits/) with lower copays at most Albany Med providers.

　　A wide array of services and programs to support emotional, physical, and mental wellbeing (http://albanymedcareers.com/benefits/employee-advantages/)

　　Anchored in the state’s historic capital city, Albany Med offers a full range outpatient and inpatient careand is home to the region’s largest hospital, only Level 1 trauma center, and only children’s hospital. Thedowntown campus also offers opportunities at Albany Medical College.

　　Albany Med partners with Columbia Memorial Health, Saratoga Hospital and Glens Falls Hospital to form the Albany Med Health System, serving more than three million people over 25 counties.