Provides concurrent and retrospective review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Key responsibility will be to review the chart for information not currently in the chart but that is indicated by clinical indicators in the record. Queries the medical staff when necessary by written and/or verbal communication to obtain accurate andcomplete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.
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 communications 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.
Demonstrates continued advancement in professional growth.
Bachelor’s
MD; MBBS or any equivalent degree
Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
Knowledge of age-specific patient needs and the elements of disease processes and related procedures.
Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
BronxCare is the largest voluntary, not-for-profit health and teaching hospital system serving the South and Central Bronx, with 859 beds and more than 4,500 employees. Its two main hospital divisions, comprehensive psychiatric and chemical dependency programs, long-term care facility, and extensive outpatient network of 39 practices are providing the wide range of services needed by the community. BronxCare is now among the largest providers of outpatient services in New York City, with close to 750,000 visits annually. Its ER is among the largest in the nation with 127,000 visits annually.
In 2023, BronxCare received full accreditation from the Joint Commission, the leading accrediting authority for hospitals in the nation. Its medical school affiliation with the Icahn School of Medicine at Mount Sinai and clinical collaboration with the Mount Sinai Health System, as well as 16 accredited residency and fellowship programs, are strong indicators of excellence. BronxCare’s outpatient practices are also certified as a Level Three Patient-Centered Medical Home (the highest designation) by the National Committee for Quality Assurance (NCQA).
As an engine for positive change, BronxCare has infused more than $400 million into the Bronx economy, including a new Pediatric Specialty Center and Ophthalmology Practice, among numerous other capital projects. A new 33-bed Medical-Surgical Unit at the Concourse Hospital Division and 20-bed Adult Psychiatric Unit at the Fulton Hospital Division will increase inpatient capacity to 912 beds, further reinforcing BronxCare’s ability to address the significant needs of the Bronx community.
BronxCare is also modernizing its Inpatient Maternity and Labor and Delivery Units, as well as its Women’s Health Center and Neurology Suite, to improve the patient experience. Additionally, BronxCare’s Dr. Martin Luther King, Jr. Health Center Practice at 174th Street will be opening.
