Clinical Documentation Specialist (CDIP or CCDS Certified)

Welcome to Northwell Health, where we are dedicated to providing exceptional patient care and advancing healthcare through innovation and research. We are currently seeking a highly skilled Clinical Documentation Specialist (CDIP or CCDS Certified) to join our dynamic team. As a Clinical Documentation Specialist, you will play a crucial role in ensuring accurate and comprehensive documentation of patient medical records. Your attention to detail and expertise in CDIP or CCDS certification will be vital in optimizing coding, reimbursement, and overall patient care. Join us in our mission to transform the healthcare industry and make a difference in the lives of our patients.

1. Review and analyze patient medical records to ensure accuracy and completeness of documentation.
2. Collaborate with healthcare providers to clarify and obtain missing or incomplete information in medical records.
3. Utilize knowledge of CDIP or CCDS certification to accurately code and document patient diagnoses and procedures.
4. Conduct regular audits of medical records to ensure compliance with coding and documentation guidelines.
5. Educate and train healthcare providers on proper documentation practices and coding guidelines.
6. Identify opportunities for improvement in the documentation process and make recommendations for enhancement.
7. Communicate with coding and billing teams to ensure accurate and timely coding and reimbursement.
8. Stay updated on industry changes and regulations related to clinical documentation and coding.
9. Participate in quality improvement initiatives to enhance patient outcomes and optimize reimbursement.
10. Maintain confidentiality and adhere to HIPAA regulations in handling patient information.
11. Work closely with interdisciplinary teams to ensure accurate and comprehensive documentation of patient care.
12. Serve as a resource for colleagues regarding documentation and coding best practices.
13. Collaborate with IT teams to ensure accurate and efficient use of electronic health record systems.
14. Uphold the mission and values of Northwell Health in all job duties and interactions with patients and colleagues.

According to JobzMall, the average salary range for a Clinical Documentation Specialist (CDIP or CCDS Certified) in Lake Success, NY, USA is $75,000-$95,000 per year. This can vary depending on the specific job responsibilities, level of experience, and the employer's compensation policies.

Northwell Health is a nonprofit integrated healthcare network that is New York State's largest healthcare provider and private employer, with more than 68,000 employees in 2019.