[Remote] CDI Document Integrity

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Note: The job is a remote job and is open to candidates in USA. Mount Sinai Medical Center is dedicated to providing high-quality healthcare and is seeking a Clinical Documentation Improvement professional to join their team. The role involves applying ICD-10 coding guidelines, reviewing patient records, and formulating queries to improve documentation accuracy and efficiency.


Responsibilities

  • Applies ICD-10 coding guidelines appropriately and has an 80% 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 beween 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 35-45% of all patient records reviewed
  • Follows up on all pending queries on a daily basis until answered. Manages the CDIS discharged open query worklist daily
  • Has good command of CDIS software and mantains an accurate data input of patient's wording DRG and baseline DRG. Records daily review notes, and all other entries required witht the software accurately.
  • 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).
  • Reviews the CDIS mismatch worklist on a regular basis to ensure working DRGs are optimal and addresses any discrepancies with HIM coding staff in an effective and timely manner
  • 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 unaswered queries that would have otherwise impacted DRG weight in CDIS query eval chapter for tracking

Skills

  • Florida Residency Required Prior To Starting
  • R.N. or Medical Graduate
  • Florida resident or open to relocation required
  • R.N. Certified preferred
  • Medical School Graduate
  • Bachelor's Degree
  • 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

Company Overview

  • Mount Sinai Medical Center provides healthcare services, including cardiology, neurology, orthopedics, endocrinology, and gastroenterology. It was founded in 1949, and is headquartered in Miami Beach, Florida, USA, with a workforce of 1001-5000 employees. Its website is https://www.msmc.com/.

    • Company H1B Sponsorship

  • Mount Sinai Medical Center has a track record of offering H1B sponsorships, with 27 in 2025, 28 in 2024, 19 in 2023, 12 in 2022, 3 in 2021, 6 in 2020. Please note that this does not guarantee sponsorship for this specific role.

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