Clinical Documentation Quality Improvement Specialist III-Mt Sinai Hospital- FT Remote

The Clinical Documentation Specialist III is a senior technician, responsible for improving the overall quality and completeness of clinical documentation, and proficient in all three grouper systems. Expert knowledge of ICD-10 CM/PCS and all current regulations. This individual facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Medical Records coding staff to ensure that documentation reflects complete and accurate level of service rendered to patients. Assumes responsibility for education of clinicians and project management as required.

1. Proficient in all (3) grouper systems, facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records.

2. Facilitates modification of clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer under Medicare.

3. Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.

4. Assists in medical screening process, making referrals, interacting with case managers and clinical nurse specialists to ensure continuity of patient care as needed.

5. Updates the DRG worksheet to monitor any changes in status, procedures/treatments, and confers with physicians to finalize diagnoses.

6. Proactively solicits clarification from physicians to ensure points of clarification have been recorded in the patients chart

7. Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations.

8. Reviews clinical issues with coding staff to assign a working DRG.

9. Educates nursing staff, patient caregivers and coding staff on compliant documentation opportunities, coding and reimbursement issues as well as provides clinical expertise to the coding staff. Takes a lead role in education and mentoring less senior staff.

10. Performs other related duties.

• RN/BSN or related health care professional preferred, with experience in med-surgical, critical care or emergency care a plus. Eligible for CAC, CCS or CCDS.
• 5 years minimum, greater preferred, as health care professional (experience in med-surgical, critical care or emergency care is desirable).
• Knowledge of ICD-10 CM/PCS and current Medicare and Medicaid regulations regarding clinical documentation and billing compliance for Part A and B services

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 $87,692.00 - $131,538.00 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.

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 he