Mount Sinai Medical Center
Overview
Join to apply for the
Clinical Documentation Spec II
role at
Mount Sinai Medical Center .
As Mount Sinai grows, so does our legacy in high-quality health care. Since 1949, Mount Sinai Medical Center has remained committed to providing access to its diverse community. In delivering an unmatched level of clinical expertise, our medical center is committed to recruiting and training top healthcare workers from across the country. We offer the latest in advanced medicine, technology, and comfort in 12 facilities across Miami‑Dade (including our 674‑bed main campus facility) and Monroe Counties, with 38 medical services, including cancer care, 24/7 emergency care, orthopedics, cardiovascular care, and more. Mount Sinai takes pride in being South Florida's largest private independent not‑for‑profit hospital, dedicated to continuing the training of the next generation of medical pioneers.
Our hardworking, tight‑knit community of more than 4,000 dedicated employees fosters an environment of care and compassion. Each member plays a vital role in our collective mission to deliver excellent healthcare through innovation, education, and research. At Mount Sinai, we take pride in our achievements, aiming to be a beacon of quality healthcare in South Florida. We welcome all healthcare professionals to join our thriving community and contribute to our pursuit for clinical excellence.
Responsibilities
Applies ICD‑10 coding guidelines appropriately and has an 85% Working DRG accuracy
Has good working knowledge of all DRG and their structure, as well as CCs and MCCs. Can discern what the impact of a query would be in order to focus efforts efficiently and determine priorities
Reviews all patient records in his/her assigned unit(s) between 24‑48 hours of inpatient admission and subsequently between 2‑3 days until discharge, as needed. Manages approximately 16‑20 charts daily
Recognizes opportunities for documentation improvement by utilizing sound clinical reasoning and critical thinking skills, as well as coding concepts
Formulates clinically credible queries to physicians and achieves a response rate and agree rate above 85% respectively.
Maintains excellent rapport and working relationship with physicians, residents, physician assistants, nurse practitioners, nurses, case managers and other healthcare providers
Maintains query rate of 25‑35% of all patient records reviewed
Follows up on all pending queries on a daily basis until answered and monitors. Manages the Epic query workqueues as well as the 3M 360 pending queries swim lanes regularly
Has good command of 3M 360 Encompass software and maintains an accurate data input of patient's working DRG and baseline DRG. Records daily review notes and all other notes required within the software accurately.
Responsible for retrospective reviews for quality and revenue projects as assigned
Properly documents query narrative and notes the expected query response and the actual response including date and location of response in the medical record (what and where).
Responsible for mentoring and training new employees in conjunction with department Manager
Reviews the mismatch report periodically to ensure working DRGs are optimal and addresses any discrepancies with HIM coding staff in an effective and timely manner.
Supports manager in reconciliation of monthly query reports and other financial reports as needed
Works individual monthly financial report to ensure accounts with financially impacting queries have the proper baseline DRG and that final DRG and working DRG match to ensure reporting is optimal
Reports accounts with unanswered queries that would have otherwise impacted DRG weight for tracking
Provides support to Rehab team by reviewing potential rehab admissions to ensure they meet CMS compliance criteria and queries Rehab physicians as needed to include supporting diagnoses. Evaluates rehab visits for potential tier improvements by querying physicians for potential qualifying diagnoses.
Qualifications
License/Registration/Certification
R.N. or Medical Graduate
Education
R.N. Certified preferred; Medical School Graduate; Bachelor's Degree
Experience
Critical Care/ Intensive Care patient care experience preferred; medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience desired
Benefits
Health benefits
Life insurance
Long‑term disability coverage
Healthcare spending accounts
Retirement plan
Paid time off
Pet Insurance
Tuition reimbursement
Employee assistance program
Wellness program
On‑site housing for select positions and more!
#J-18808-Ljbffr
Clinical Documentation Spec II
role at
Mount Sinai Medical Center .
As Mount Sinai grows, so does our legacy in high-quality health care. Since 1949, Mount Sinai Medical Center has remained committed to providing access to its diverse community. In delivering an unmatched level of clinical expertise, our medical center is committed to recruiting and training top healthcare workers from across the country. We offer the latest in advanced medicine, technology, and comfort in 12 facilities across Miami‑Dade (including our 674‑bed main campus facility) and Monroe Counties, with 38 medical services, including cancer care, 24/7 emergency care, orthopedics, cardiovascular care, and more. Mount Sinai takes pride in being South Florida's largest private independent not‑for‑profit hospital, dedicated to continuing the training of the next generation of medical pioneers.
Our hardworking, tight‑knit community of more than 4,000 dedicated employees fosters an environment of care and compassion. Each member plays a vital role in our collective mission to deliver excellent healthcare through innovation, education, and research. At Mount Sinai, we take pride in our achievements, aiming to be a beacon of quality healthcare in South Florida. We welcome all healthcare professionals to join our thriving community and contribute to our pursuit for clinical excellence.
Responsibilities
Applies ICD‑10 coding guidelines appropriately and has an 85% Working DRG accuracy
Has good working knowledge of all DRG and their structure, as well as CCs and MCCs. Can discern what the impact of a query would be in order to focus efforts efficiently and determine priorities
Reviews all patient records in his/her assigned unit(s) between 24‑48 hours of inpatient admission and subsequently between 2‑3 days until discharge, as needed. Manages approximately 16‑20 charts daily
Recognizes opportunities for documentation improvement by utilizing sound clinical reasoning and critical thinking skills, as well as coding concepts
Formulates clinically credible queries to physicians and achieves a response rate and agree rate above 85% respectively.
Maintains excellent rapport and working relationship with physicians, residents, physician assistants, nurse practitioners, nurses, case managers and other healthcare providers
Maintains query rate of 25‑35% of all patient records reviewed
Follows up on all pending queries on a daily basis until answered and monitors. Manages the Epic query workqueues as well as the 3M 360 pending queries swim lanes regularly
Has good command of 3M 360 Encompass software and maintains an accurate data input of patient's working DRG and baseline DRG. Records daily review notes and all other notes required within the software accurately.
Responsible for retrospective reviews for quality and revenue projects as assigned
Properly documents query narrative and notes the expected query response and the actual response including date and location of response in the medical record (what and where).
Responsible for mentoring and training new employees in conjunction with department Manager
Reviews the mismatch report periodically to ensure working DRGs are optimal and addresses any discrepancies with HIM coding staff in an effective and timely manner.
Supports manager in reconciliation of monthly query reports and other financial reports as needed
Works individual monthly financial report to ensure accounts with financially impacting queries have the proper baseline DRG and that final DRG and working DRG match to ensure reporting is optimal
Reports accounts with unanswered queries that would have otherwise impacted DRG weight for tracking
Provides support to Rehab team by reviewing potential rehab admissions to ensure they meet CMS compliance criteria and queries Rehab physicians as needed to include supporting diagnoses. Evaluates rehab visits for potential tier improvements by querying physicians for potential qualifying diagnoses.
Qualifications
License/Registration/Certification
R.N. or Medical Graduate
Education
R.N. Certified preferred; Medical School Graduate; Bachelor's Degree
Experience
Critical Care/ Intensive Care patient care experience preferred; medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience desired
Benefits
Health benefits
Life insurance
Long‑term disability coverage
Healthcare spending accounts
Retirement plan
Paid time off
Pet Insurance
Tuition reimbursement
Employee assistance program
Wellness program
On‑site housing for select positions and more!
#J-18808-Ljbffr