Clinical Documentation Improvement (CDI) Specialist
Job No: 496192
Department: MEDICAL RECORDS
Local Title: Clinical Documentation Improvement (CDI) Specialist
Budget Title: Th Utilization Review and Quality Assurance Senior Coordinator
Work Type: Full Time
Location: Brooklyn, NY
Categories: Information Technology, Nursing, Clinical
Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors.
Bargaining Unit:
UUP
Job Summary:
The Department of Health Information Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review and Quality Assurance Senior Coordinator / Clinical Documentation Improvement (CDI) Specialist.
Reporting to the CDI Manager and Director of Health Information Management, the successful candidate will:

• Demonstrate excellent interpersonal skills, including verbal and written communication, to develop relationships necessary to influence physician document process.
• Demonstrate the ability to prioritize and be self-directed and capable of independent decision making.
• Demonstrate analytic skills necessary to clinically assess medical records, including critical thinking, problem solving and deductive reasoning skills.
• Demonstrate the ability to organize and present information clearly and concisely.
• Possess basic computer skills including Microsoft products Office, Excel and PowerPoint.
• Possess working knowledge of Medicare reimbursement and coding structures.
• Be responsible for reviewing medical records to facilitate clinical documentation that accurately reflects the patient severity of illness and risk of mortality by improving the quality of the physician clinical documentation. This involves extensive record review, interaction with physicians, residents, advanced practice nurses, ancillary providers, coding and HIM professionals and nursing staff.
  • Key Competencies include:
    • Foundational Thinking Skills: Review inpatient medical records for identified payer populations (Medicare, Medicaid, Blue Cross/Blue Shield, and others) as directed on admission and throughout hospitalization.
    • Strategic Management: In collaboration with physician leadership, design and implement specific tools to support medical record physician documentation.
    • Human Resources Leadership Skills: Develop and implement plans for both formal and informal education of physician, nursing, and other clinical staff.
    • Relationship Management: Communicate with attending physician and other relevant clinical staff, either verbally or through written methodology.
    • Personal and Professional Accountability: Maintain good rapport and cooperative relationships. Approach conflict in a constructive manner. Help identify problems, offer solutions, and participate in their resolution.
    • Career Planning: Assure personal and professional growth through self-study/attendance/participation in seminars and workshops.
    • Fostering Professional Environment: Maintain the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to the Medical Center.
    • Optimizing the Leader within/Reflective Practice Behaviors: Behave in accordance with mission, vision, and values of the Medical Center. Demonstrate integrity, truthfulness and fairness when working with others. Create an environment of acceptance and respect in the work place.
    • Cultural Competence: Integrate knowledge of cultural competence and inclusion in all daily practices such as assessment, documentation, communication, etc.
    • Shared Decision Making: Works closely with Health Information Management coding staff to assure documentation of discharge diagnosis (es) and any co-existing co-morbidities are a complete reflection of the patient clinical status and care.
    • Performance Improvement: Contribute to organizational, departmental and unit-based process improvement activities.
    • Technology: Demonstrate and maintain competency and accuracy in use of software applications including capability in Microsoft Office applications.
    • Clinical Practice Knowledge and Skill: Conduct daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity.

Required Qualifications:

• New York State Registered Nurse License.
• 3 years of acute care nursing experience.
• 2 to 3 years of clinical documentation improvement experience.
• DO, MBBS, or foreign educated medical graduate.

Preferred Qualifications:

• Certification in Clinical Documentation Improvement CCDS or CDIP preferred.

Work Schedule:
Monday to Friday; 9:00am to 5:00pm
Salary Grade/Rank:
SL-4
S alary Range:
Commensurate with experience and qualifications
E xecutive Order:
Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor's Office of Employee Relations at (518) 474-6988 or via email at info@goer.ny.gov.
Equal Employment Opportunity Statement:
SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws.
Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply.
If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at ada@downstate.edu
Advertised: January 29, 2024 Eastern Standard Time
Applications close: