Job Description

Clinical Documentation Specialist

The Clinical Documentation Specialist (CDS) at BronxCare Health System plays a critical role in ensuring the accuracy, completeness, and integrity of patient medical records. This position 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.

Qualifications

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

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