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Clinical Documentation Improvement Specialist, Mount Vernon



Mount Vernon, United States 

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Job Description:

About the company:

Accuity Delivery Systems was founded in 2016 with the goal of reinventing the Clinical Documentation Process through MD case review, and MD to MD education. Over the last two years, we have experienced rapid growth and are excited to continue in growing our team in 2018. Learn more about us at www.accds.com.

Position summary:

The Clinical Documentation Improvement Specialist uses clinical and coding knowledge for conducting clinically based concurrent reviews of inpatient medical records to evaluate the clinical documentation of clinical services and identifies opportunities for improving the quality of medical record documentation.

Position responsibilities:

  • 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 care of the patient.
  • Contributes to content development and provider education (formal and informal).
  • Contributes to ongoing service line documentation improvement initiatives, including formal and informal provider education plans,
  • Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician’s clinical documentation.
  • Initiates medical record review within 24 to 48 hours of admission.
  • Monitors, systematically, the targeted medical records within at least 48 hours (unless otherwise indicated) to determine compliance to established documentation standards.
  • Conducts follow-up reviews to ensure clarification has been documented in the medical record and Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG.
  • Addresses abnormal ancillary test findings when they occur and query physicians on a current basis to include face-to-face interactions regarding the impact on patient care and DRG assignment.
  • Initiates physician interaction when ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
  • Partners with the HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, risk of mortality and quality outcomes.
  • Contributes to provider engagement, relationship establishment and maintenance related to CDI and documentation improvement efforts, with all providers.
  • Contributes to ongoing service line documentation improvement initiatives, including formal and informal provider education plans

Job Requirements:


At least one of the following:

  • Foreign Medical Graduate
  • Associates Degree in Nursing
  • Bachelor’s Degree in Nursing
  • Other related degree will be reviewed as the discretion of management


  • 3-5 years of clinical work experience, and 2-5 years of CDI and/or Inpatient coding experience equivalent to coding


At least one of the following:

  • MD
  • CDIP
  • RN
  • BSN
  • CCS

Knowledge, Skills, and Abilities

  • Excellent communication skills.
  • Very strong writing skills, appropriate punctuation, grammar etc.
  • Excellent critical thinking skills
  • Strong computer skills with the ability to learn multiple EMR systems as well as data reporting systems
  • Ability to analyze data, perform multiple tasks and work independently.
  • Must be able to develop and maintain professional, service-oriented working relationships with all staff especially ACCDS physician reviewers.
  • Must be able to understand and comply with policies and procedures

Company Info
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