About This Role
The Clinical Documentation Specialist (CDS) at BronxCare Health System ensures the accuracy, completeness, and integrity of patient medical records. This role 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.
Responsibilities
- Establish 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 stakeholders
- Meet 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 documentation
- Meets 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
Requirements
- Foreign medical graduates or students from accredited program
- MD
- Minimum of 1 year experience within a patient care environment
- Basic computer skills including Microsoft Office
- Excellent verbal and written communication
- Must be able to work in a high-volume team environment
- Detailed oriented
