Documentation Specialist

• Facilitate improvement of medical record documentation through concurrent and retrospective interventions
• Interact with and educate physicians, residents, and other licensed independent practitioners
• Develop processes to identify documentation improvement opportunities
• Intervene with attending physicians, residents, and physician extenders
• Provide routine in-services on regulatory documentation requirements and clinician documentation impacts on Service Line metrics
• Maintain records and databases quantifying documentation deficits, interventions, and impact
• Conduct interventions and ensure follow-through on recommendations
• Identify, investigate, and evaluate practices and processes for continuous documentation improvement
• Participate in retrospective medical record reviews to collect data and resolve coding or documentation discrepancies
• Maintain knowledge of coding, billing, documentation guidelines, and third-party payer requirements
• Collaborate with the Manager of Coding Unit
• Educate therapy staff and clinicians on correct billing, coding, and documentation
• Perform other job-related duties as assigned

Explore Documentation Improvement Specialist, CDI at NewYork-Presbyterian Hospital. Review requirements and application details.