Residence Requirements:

RESIDENCE REQUIREMENTS: THERE ARE NO RESIDENCY REQUIREMENTS FOR PARTICIPATION IN THIS EXAMINATION. There are two anticipated vacancies at the Erie County Medical Center Corporation.

Examples of Duties:

A Clinical Documentation Specialist ensures the overall quality and completeness of clinical documentation for patients at the Erie County Medical Center Corporation; 

Reviews inpatient medical records for identified payer populations, such as Medicare, Medicaid, or health insurances, as directed on admission and throughout hospitalization;

Analyzes clinical status of patient, current treatment plan and past medical history; identifies potential gaps in physician documentation;

Communicates with attending physicians and residents to validate observations and suggests additional and/or more specific documentation;

Works closely with Coding Staff to assure documentation of discharge diagnoses and co-existing co-morbidities are a complete reflection of the patient’s clinical status and care;

Ensures timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes;

Develops and implements plans for education of physicians, nursing and other clinical staff; educates staff on documentation improvement;

Collaborates with physician administrators to design and implement specific tools to support medical record physician documentation;

Identifies strategies for sustained work process changes that facilitate complete and accurate clinical documentation;

Establishes and monitors programs for quality control of accuracy, completeness and timeliness of documentation;

Analyzes, interprets and reports findings of program impact to management, physicians, patient care team, coding staff and other clinical staff;

Facilitates multidisciplinary team efforts for clinical documentation improvement;

Demonstrates and applies basic knowledge of the American Health Information Management Association Standards of Coding for evaluation of medical record documentation;

Meets established productivity targets for record review.

Qualifications:

MINIMUM QUALIFICATIONS: Candidates must meet one of the following requirements on or before the date of the written test:

A) Graduation from a regionally accredited or New York State registered college or university with a Bachelor’s Degree in Nursing and three (3) years of experience in inpatient medical/surgical or critical care; or

B) Graduation from a regionally accredited or New York State registered college or university with an Associates’ Degree in Nursing and five (5) years of experience in inpatient medical/surgical or critical care; or

C) An equivalent combination of training and experience as defined by the limits of (A) and (B).

SPECIAL REQUIREMENT:

Possession of a license and current registration to practice as a Registered Nurse in the State of New York. 

Notes:

1. Verifiable part-time and/or volunteer experience will be pro-rated toward meeting the experience requirements.

2. Your degree and/or college credit must have been awarded by a regionally accredited college or university or one recognized by the New York State Education Department as following acceptable educational practices. A grade of "D" or better is necessary for a course to be credited as successfully completed. If your degree and/or college credit was awarded by an educational institution outside of the United States and its territories, you must provide independent verification of equivalency. You can write to this Department for a list of acceptable companies providing this service; you must pay the required evaluation fee.

Notice to Candidates: Transcripts will now be accepted by the Department of Personnel ONLY at time of application. All subsequent transcripts must be submitted at time of interview.

The New York State Department of Civil Service has not prepared a test guide for this examination. However,candidates may find information in the publication "How to take a written test" helpful in preparing for this test. This publication is available on line at: www.cs.ny.gov/testing/localtestguides.cfm

Subjects of Examination:

SUBJECTS OF EXAMINATION: A written test designed to evaluate knowledge, skills and /or abilities in the following areas:

1. Evaluating health care

These questions test for knowledge of medical symptoms, diagnoses, treatments, and federal and New York State quality assurance standards and discharge planning; for the ability to apply this knowledge to given situations; and for the ability to evaluate client care and treatment.

2. Medical, psychiatric, developmental conditions and treatments

These questions will test for knowledge in areas such as: acceptable treatments and standard medical alternatives; symptoms, tests, procedures, and treatments associated with specific diagnoses; evaluation of the appropriateness of treatment methods; characteristics of the various populations diagnosed with mental illness or intellectual/developmental disabilities.

3. Preparing written material

These questions test for the ability to present information clearly and accurately, and to organize paragraphs logically and comprehensibly. For some questions, you will be given information in two or three sentences followed by four restatements of the information. You must then choose the best version. For other questions, you will be given paragraphs with their sentences out of order. You must then choose, from four suggestions, the best order for the sentences.

4. Understanding and interpreting health records and reports

These questions test for the ability to read, interpret, and apply information used in evaluating health care. You will be required to read and interpret selections from medical records and reports; laws, rules, and regulations relating to health care; and/or narratives on health-related topics.

NOTICE TO CANDIDATES: Unless otherwise noted, candidates are permitted to use quiet, hand held, solar or battery powered calculators. Devices with typewriter keyboards, "Spell Checkers", “Personal Digital Assistants", "Address Books", "Language Translators", "Dictionaries", or any similar devices are prohibited. You may not bring books or other reference materials.

**IMPORTANT APPLICATION FEE - READ CAREFULLY**

A $20.00 filing fee is required for this exam. The required fee must accompany your application. Send or bring check or money order made payable to Erie County Personnel Department and write the examination number(s) on your check or money order. Do not send or bring cash, as the County cannot be responsible for cash payment. As no refund will be made, you are urged to compare your qualifications carefully with the requirements for admission and file only for those examinations for which you are clearly qualified.