MSHP seeks a Clinical Documentation Specialist who will support efforts to
improve the overall quality and completeness of clinical documentation and
coding in outpatient physician practices. They will work closely with
physicians, Health Information Management and the Mount Sinai Health Partners
team to review and code ambulatory medical records, identify opportunities to
improve coding, educate physicians, and act as a liaison between all parties.
RESPONSIBILITIES
Facilitates improvement in the overall quality, completeness and accuracy of
medical record documentation and coding.
Reviews charts to assess the clinical status of patients, current treatment
plan, and past medical history to identify potential gaps in clinical
documentation related to outpatient encounters, with a particular focus on
primary care visits.
Performs on-site or electronic coding and clinical validation audits and
interpretation of medical documentation to ensure capture of all relevant
coding. A particular focus with be on Hierarchical Condition Categories (HCC)
coding, which is used by CMS and other payers to determine illness complexity
and estimate patient risk of future health care utilization.
Leverages data provided by available information technology (such as billing
data) to identify additional opportunities to improve the comprehensiveness
and specificity of outpatient coding
Communicates and coordinates chart reviews with physician office staff and
distributes correspondence related to review.
Analyzes returned CDQI alerts for accuracy and completeness
Reviews outpatient visit diagnoses and service levels prior to claim
submission to ensure they accurately reflect the clinical status of patients
and the type of care delivered
Proactively solicits clarification from physicians to ensure key aspects of
care have been appropriately recorded in the patient’s chart
Participates in data acquisition, development of performance reports and
communication of results to physicians, practice managers, and the CDQI
leadership team
Interacts regularly with physicians, particularly primary care providers, in
the outpatient setting, providing ongoing education regarding compliant
documentation and accurate coding, and serves as clinical liaison to the
coding department
Identifies training needs, prepares summary reports and conducts coaching as
appropriate for clinicians and other staff to improve the quality of the
documentation to accurately reflect members’ health status.
Monitors coding changes by governmental agencies and other payers; educates
practices on coding and compliance issues
Monitors activities to ensure that all clinical documentation is in
compliance with State and Federal payer regulations
Performs other related duties.
QUALIFICATIONS
Education and Experience
High school diploma or general education degree (GED); Associates or greater
preferred
Must have a minimum of 3 years coding experience
At least 1 year of HCC Risk Adjustment experience, preferred
Clinical background in a healthcare setting, preferred
Credentials in one or more of the following, required:
Certified Coding Specialist (CCS)
Certified Risk Adjustment Coder (CRC)
Certified Professional Coder (CPC)
Additional Skills and Qualities
Demonstrated experience with front-end process improvement initiatives
Thorough knowledge of ICD-10, CPT, and HCPCS
Familiarity and understanding of CMS HCC Risk Adjustment coding and data
validation requirements
Familiarity with APC coding
Experience with Microsoft Excel and Strong communication and mentoring skills
Ability to communicate clearly and effectively with a wide variety of
individuals at all levels of the organization
Strong time management skills
Excellent organization skills
Must possess high degree of accuracy, efficiency and dependability
Excellent written and oral communication for representation of clear and
concise results
Compensation Statement
The Mount Sinai Health System (MSHS) provides salary ranges that comply with the
New York City Law on Salary Transparency in Job Advertisements. The salary range
for the role is $65,885.00 - $98,827.00 Annually. Actual salaries depend on a
variety of factors, including experience, education, and operational need. The
salary range or contractual rate listed does not include bonuses/incentive,
differential pay or other forms of compensation or benefits.
Non-Bargaining Unit, E01 - Partner MSO Services - MSH, Mount Sinai Hospital
Strength through Unity and Inclusion
The Mount Sinai Health System is committed to fostering an environment where
everyone can contribute to excellence. We share a common dedication to
delivering outstanding patient care. When you join us, you become part of Mount
Sinai’s unparalleled legacy of achievement, education, and innovation as we work
together to transform healthcare. We encourage all team members to actively
participate in creating a culture that ensures fair access to opportunities,
promotes inclusive practices, and supports the success of every individual.
At Mount Sinai, our leaders are committed to fostering a workplace where all
employees feel valued, respected, and empowered to grow. We strive to create an
environment where collaboration, fairness, and continuous learning drive
positive change, improving the well-being of our staff, patients, and
organization. Our leaders are expected to challenge outdated practices, promote
a culture of respect, and work toward meaningful improvements that enhance
patient care and workplace experiences. We are dedicated to building a
supportive and welcoming environment where everyone has the opportunity to
thrive and advance professionally. Explore this opportunity and be part of the
next chapter in our history.
About the Mount Sinai Health System:
Mount Sinai Health System is one of the largest academic medical systems in the
New York metro area, with more than 48,000 employees working across eight
hospitals, more than 400 outpatient practices, more than 300 labs, a school of
nursing, and a leading school of medicine and graduate education. Mount Sinai
advances health for all people, everywhere, by taking on the most complex health
care challenges of our time — discovering and applying new scientific learning
and knowledge; developing safer, more effective treatments; educating the next
generation of medical leaders and innovators; and supporting local communities
by delivering high-quality care to all who need it. Through the integration of
its hospitals, labs, and schools, Mount Sinai offers comprehensive health care
solutions from birth through geriatrics, leveraging innovative approaches such
as artificial intelligence and informatics while keeping patients’ medical and
emotional needs at the center of all treatment. The Health System includes more
than 9,000 primary and specialty care physicians; 13 joint-venture outpatient
surgery centers throughout the five boroughs of New York City, Westchester, Long
Island, and Florida; and more than 30 affiliated community health centers. We
are consistently ranked by U.S. News & World Report's Best Hospitals, receiving
high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in
Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology,
Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics,
Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear
Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World
Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's
Hospital among the country’s best in several pediatric specialties. The Icahn
School of Medicine at Mount Sinai is ranked No. 11 nationwide in National
Institutes of Health funding and in the 99th percentile in research dollars per
investigator according to the Association of American Medical Colleges.
Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as
No. 1 in New York and in the top five globally, and Mount Sinai Morningside in
the top 20 globally.
Equal Opportunity Employer
The Mount Sinai Health System is an equal opportunity employer, complying with
all applicable federal civil rights laws. We do not discriminate, exclude, or
treat individuals differently based on race, color, national origin, age,
religion, disability, sex, sexual orientation, gender, veteran status, or any
other characteristic protected by law. We are deeply committed to fostering an
environment where all faculty, staff, students, trainees, patients, visitors,
and the communities we serve feel respected and supported. Our goal is to create
a healthcare and learning institution that actively works to remove barriers,
address challenges, and promote fairness in all aspects of our organization.