Clinical Documentation Specialist

Clinical Documentation SpecialistThe Clinical Documentation Specialist (CDS) at BronxCare Health System plays a critical role in ensuring the accuracy, completeness, and integrity of patient medical records. This position serves as a key liaison between clinical staff, coding professionals, and administrative teams to support high-quality documentation that reflects the severity of illness, risk of mortality, and complexity of care delivered. The CDS contributes directly to improved patient outcomes, regulatory compliance, and appropriate reimbursement.ResponsibilitiesEstablish and maintain positive relationships with patients, visitors and other employees. Interacts professionally, courteously, and appropriately with patients, visitors, and other employees. Behave in a manner consistent with maintaining and furthering a positive public perception of BronxCare Health System and its employees.Contribute to and participate in the Performance/Quality Improvement activities of the assigned department. Contribution and participation includes data collection, analysis, implementation of and compliance with corrective/improvement activities, membership on CQI teams, consistent adherence to established performance standards and: adherence to the specific rules and regulations of the BronxCare Health System's Safety & Security Policies; Risk Management: Incident and Occurrence Reporting; Infection Control Policies and Procedures; Patient and Customer Service.Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholdersMeet CDI program objectives, goals, and balance scorecard metrics.Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.Ensure effective communication with key stakeholders.Analyzes data, creates reports to meet desired outcomes.Identifies trends and opportunities for improvement in clinical documentationMeets program quality and productivity guidelines and standards.Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.Work effectively with CDI team members to accomplish departmental goals.QualificationsRequirements:Foreign medical graduates or students from accredited program.MDMinimum of 1 year experience within a patient care environment.Basic computer skills including Microsoft OfficeExcellent verbal and written communicationMust be able to work in a high-volume team environmentDetailed oriented