Campus Description: The best ideas in medicine start with the best people. At Stony Brook Medicine, our highest calling is to put the power of ideas to work in our patients’ lives. Stony Brook Medicine integrates and elevates all of Stony Brook University’s health-related initiatives: education, research and patient care. It includes Stony Brook University Hospital, Long Island’s premier academic medical center. With 597 beds, SBUH is the region’s only tertiary care center and Level 1 Trauma Center. We are home of the Stony Brook Heart Institute, Stony Brook Cancer Center, Stony Brook Long Island Children’s Hospital, Stony Brook Neurosciences Institute, and Stony Brook Digestive Disorders Institute. At Stony Brook Medicine, we put the power of ideas to work. Join our team at Stony Brook Medicine – the best ideas in medicine.
Descriptive Title: Clinical Documentation SpecialistREF#: UH-S-5637.01-13-S
Budget Title: TH Staff AssociateState Professional Position
Department: Health Information ManagementState Line#: 13097
Grade: SL-4Campus: Stony Brook-University Hospital
Salary: Commensurate with experience
THIS POSTING IS NOT CURRENT !!!
Required Qualifications: Current NYS RN License with Bachelors Degree or advanced licensure of Nurse Practitioner or Physician Assistant. Minimum of five years hospital acute care nursing experience. Computer proficiency with a working knowledge of Word, Excel and Powerpoint. Excellent written and verbal communication skills. Critical thinking and interpersonal skills to build effective relationships with physician, case management, nursing and HIM Staff.
Preferred Qualifications: Previous clinical documentation improvement experience. CCDS credential. Formal CDS training. Surgery/SICU or ICU experience. Recent quality management, core measure or clinical decision support experience.

Brief Description of Duties:
  • Improves the overall quality and completeness of concurrent inpatient documentation by performing initial and follow up reviews to facilitate appropriate reimbursement and compliance with performance measures.
  • Interacts and communicates with physician staff daily, clarifying documentation in the medical record through verbal, electronic and paper query. Providing follow up to ensure points of clarification have been recorded in the medical record.
  • Identifies appropriate principal diagnosis to establish a working DRG assignment and average length of stay. Maintain DRG worksheet to include abstraction of patient's clinical findings relevant to principal and secondary diagnosis and procedures.
  • Demonstrates knowledge of DRG payer issues, appropriate DRG assignment alternatives, clinical documentation requirements of core measures and improves the overall quality and completeness of the medical record.
  • Works in coordination with the Physician Advisor and Assistant Director of CDI to develop and present physician and staff education on documentation, coding, quality and regulatory performance.
  • Works in coordination with coding specialists to ensure appropriate reimbursement based on clinical level of service.
  • All other duties as assigned.

Special Notes: Full-time day 8am-430pm position. Please note Stony Brook Medicine is a smoke free environment. All Hospital positions are subject to changes in pass days and shifts as necessary. This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.

Please note: Prior to start date, the selected candidate must meet the following requirements: Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services, clear a background investigation; submit (3) written references, and provide a copy of the required license(s)/certificate(s). Please be advised that failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.

The selected candidate must successfully clear a background investigation.

Application Procedure: Those interested in applying for the above position should submit a state application, resume and cover letter reflecting UH# to:
Stony Brook Medicine
UH Human Resources
Professional Employment
3 Technology Drive, Suite 100
East Setauket , NY 11733-4073


Applications for this position must be received, as specified in the Application Procedure Section, no later than 5:00 PM Eastern Time on 03/21/2013, unless specifically noted otherwise in the Special Notes Section.

STONY BROOK UNIVERSITY IS AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER. WE ENCOURAGE PROTECTED VETERANS, INDIVIDUALS WITH DISABILITIES, WOMEN AND MINORITIES TO APPLY.
IF YOU NEED A DISABILITY-RELATED ACCOMMODATION, PLEASE CALL THE UNIVERSITY HUMAN RESOURCE SERVICES DEPARTMENT AT (631) 632-6161 OR THE UNIVERSITY HOSPITAL HUMAN RESOURCES DEPARTMENT AT (631) 444-4700.
IN ACCORDANCE WITH THE TITLE II CRIME AWARENESS AND SECURITY ACT, A COPY OF OUR CRIME STATISTICS IS AVAILABLE UPON REQUEST BY CALLING (631) 632-6350. IT CAN ALSO BE VIEWED ON-LINE AT THE UNIVERSITY POLICE WEBSITE AT http://www.stonybrook.edu/police

Job Category: B) Administrative and Professional Positions (excluding teaching and patient/clinical care).
Posting Date: 02/21/2013
Additional Categories: D) Health Service (including Physician Assistant, Patient Care Specialist).