Clinical Documentation Query Writer-Mt Sinai Hospital- FT- Days- Remote

The Clinical Documentation Query Writer is responsible for the review of the inpatient medical record information for facilitating and distributing compliant queries to appropriate providers to obtain optimal quality documentation ensuring proper translation of the medical record and capture of the true clinical picture of each patient. The Query Writer also selects and assigns the correct ICD-10-CM/PCS codes to the documented diagnoses, procedures, and treatments, and calculates the appropriate DRG groupings. The coded clinical data is utilized for the continued evaluation and improvement of the quality of patient care, performance improvement, education, research, hospital reimbursement, and public health reporting.

1. Ability to write queries that are concise and easily understood by the queried provider in accordance with AHIMA and ACDIS compliant query guidelines as well as American Hospital Association (AHA) Coding Clinic Guidelines, ensuring that proper medical diagnoses and procedures are being submitted for reimbursement.

2. Constructs queries with attention to detail, utilizing proper grammar and punctuation.

3. Utilizes ICD-10 coding guidelines and medical terminology to expertly create a query which results in improved accuracy of patient severity of illness, and/or risk of mortality representing the patient’s true clinical picture in final code assignment.

4. Performs query follow ups in a timely manner and update responses in the appropriate applications.

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

6. Timely reconciliation of all cases, to include accurate recording of DRG or SOI impact based on query, as well as response to all queries.

7. Abides by all Federal and New York State regulations, as dictated by CMS, Medicaid, and third party payers regarding reimbursement for the facility.

8. Abides by the Standards of Ethical Coding as set forth by AHIMA.

9. Adheres and enforces all requirements related to HIPAA and confidentiality, privacy and security of patient records.

10. Maintains expected productivity and quality standards.

11. Keeps pace with the technological and clinical advances in the medical and health information management field and maintains AHIMA professional credentials.

12. Communicates, cooperates and maintains good working relationships with administrative, clinical, hospital and departmental staff.

Education Requirements

• High School Graduate or GED; Associate Degree preferred.

 

Experience Requirements

• 1-2 years of CCA, CCS, CDIP or CCDS or equivalent

 

Licensing and Certification Requirements

• ICD-10-CM/PCS Coding Certificate in approved program preferred

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 hig