Clinical Documentation Query Writer-Mt Sinai Hospital- FT- Days
Clinical Documentation Query Writer-Mt Sinai Hospital- FT- Days
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Salary Not Disclosed
1 Vacancy
Job Description
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.
Responsibilities
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 patients 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.
Qualifications
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
Employment Type
Full-Time
