Clinical Chart Reviewer, Coordinating Manager

at NYC Health + Hospitals
Published May 29, 2022
Location New York, NY
Category Default  
Job Type Full-time  


About NYC Health + Hospitals

Empower Every New Yorker — Without Exception — to Live the Healthiest Life Possible

NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city’s five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute care/long-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

In its century of service, Coney Island Hospital has established its reputation for clinical excellence and culturally competent care. The hospital has been recognized for its clinical innovations in Primary Care, Adolescent Medicine, Nuclear Medicine and Emergency Services. The hospital's staff is as diverse as the patients they serve. Interpreter services can be provided at any time of the day or night in over 130 languages.

Job Description


Under the general supervision of the Associate Director for Quality Management, the Coordinating Manager B -Clinical Chart Reviewer provides guidance and support to multidisciplinary teams of healthcare professionals related to Hospital-Wide Quality, Performance Improvement, Regulatory compliance and Patient Safety activities. Provides on-going medical record reviews/data abstraction for quality of care indicators as defined by regulatory agencies including, but not limited to: TJC, CMS, DOH, NSQIP, and voluntary regulatory bodies and quality reporting programs.

Specific Duties and Responsibilities:

The Coordinating Manager B /Clinical Chart Reviewer is charged with and responsible for:

  • Serves as the Departmental lead for various core measures data abstraction, monitoring, analysis, and presentation:
  • o Performs the required number of monthly medical record abstractions as assigned and according to schedule determined by the Associate Director. Performs accurate and timely entry of data into the designated website or database, and assures the transmission of completed and accurate data, within designated deadline. Abstractions may include, but are not limited to the following measures:

- Outpatient ED

- Influenza Immunization (IMM-2)

- CMS Sepsis (SEP-1)


- DOH Sepsis

- ED quality monitors and checklists

- Inpatient quality monitors and checklist

- MI

- Total Hip/Total Knee Replacement

- Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

- Perinatal Care 1-6: Elective Delivery, Cesarean Birth, Exclusive Breast Milk Feeding and Unexpected Complications in Term Newborns.

- HBIPS Discharge: Violence Risk, Substance Use, Trauma, Patient Strength Screening and Multiple Antipsychotics Medications at Discharge with Appropriate Justification

- Global-IPFQR: Influenza Immunization, Alcohol Brief Intervention, Tobacco Use Treatment, Screening for Metabolic Disorders, Transition Record with Specified Elements Received by Discharge

- Leapfrog measures

  • Conducts concurrent chart reviews for the stroke program and other programs requiring time-sensitive data abstraction.
  • Reviews/edits/corrects/revises Fall-Out Report before data submission.
  • Ensures accurate data reporting for abstractions and quality measures with no less than 95% inter-rater reliability.
  • Responsible for identifying opportunities for quality improvement, through analysis of data, and will be responsible for facilitating such opportunities for improvement in collaboration with key stakeholders. Provides feedback to clinicians and program coordinators based on reviews and findings.
  • Analyzes quality indicator reports and develops presentations to leverage core measure data for use in hospital wide quality improvement efforts.
  • Attends meetings and acts as an educational resource regarding the quality measures program
  • Prepares data report for Departmental meetings and leaders in an effective way and presents to stakeholders
  • Leads and coordinates team meetings to discuss data analysis and improvement needs
  • Participates in audits conducted by regulatory agencies i.e. DOH, CMS, TJC
  • Provides Quarterly Reports to Central Office QAPI Board Report
  • Submits inquiries for clarification to Premier/DOH/CMS/ IPRO/NSQIP as needed
  • Identifies patients for inclusion in quality databases, based on program protocol, collects compliance and audit data for the program through the effective utilization of the hospital medical record system and audit tools, and provides feedback on data to staff to drive improvement.
  • Contacts patients and/or families by telephone and/or written correspondence to record data of any relevant occurrences, associated with quality programs
  • Meets quality program caseload accrual requirements with weekly completion benchmarks set by supervisor to meet the needs of the organization
  • Successfully complete Training/Certification for quality programs and annual competency certification and continuing education requirements
  • Serves as a resource to the organization for Quality, Regulatory compliance and Patient Safety.
  • Facilitates data collection responsibilities for Value Based Purchasing and other publicly reported indicators, and other measures as determined by NYC Health + Hospitals or the Performance Improvement Committee.
  • Coordinates and leads onsite visits from regulatory agencies as needed, including determining whether all regulatory and program requirements are completed and facilitating improvement (in collaboration with stakeholders) of any non-compliant items
  • Responds to regulatory statements of deficiencies or requests for information in a timely and accurate manner.
  • Participates in root cause analysis and proactive risk assessment processes as required
  • Contributes to an information database of continuous compliance and patient safety issues for planning, priority setting, analysis and trending.
  • Participates in completing Coney Island Hospital’s Quarterly Report to the Governing Body and other NYC Health + Hospitals reports as required, ensuring all entries are accurate and follows up on outstanding reports.
  • Provides and assists with interpretation and education of TJC standards / intent.
  • Performs regulatory mock tracer activities as assigned.
  • Literature review of Patient Safety and Performance Improvement processes and benchmarks to improve practices.
  • Manage, coordinate, and monitor data collection and analysis on performance improvement, patient safety and continuous compliance related issues as appropriate.
  • Assist in assessing organizational compliance with accreditation standards and regulations.
  • Helps identify areas of vulnerability related to continuous compliance, performance improvement, and patient safety.
  • Assists in developing strategies and corrective actions to enhance continuous compliance and patient safety.
  • Support the process of identifying staff training needs and assist as appropriate in developing effective employee education programs to enhance continuous compliance.
  • Develop and provide presentations as needed/assigned.
  • Perform all duties in alignment with the mission, vision, values, and behavioral expectations of NYC Health + Hospitals
  • Other duties as assigned.

Minimum Qualifications

1. A Master’s degree from an accredited college or university in Public Health, Public Administration, Business Administration, Social Work, Psychology or Rehabilitation Counseling; and

2. Two (2) years of full-time experience in medically-oriented health care and medical support systems environment, one (1) year of which included experience in an administrative or supervisory capacity in such occupations as physical, occupational, inhalation, speech and audiology therapy or as Medical/Laboratory Technologist, Microbiologist (various specialties), Chemist (biochemist), Radiation and X-Ray Technician; or two (2) years of responsible level experience in business management systems or general administration including one (1) year in a supervisory or administrative capacity; or

3. A Baccalaureate degree from an accredited college or university in disciplines listed in “1” above; and

4. Three (3) years of full-time experience, as described in “2” above, including two (2) years of experience in an administrative or supervisory capacity in occupations, as listed in “2” above; or

5. A satisfactory equivalent combination of education, training and/or experience.

Note: Certification or licensure may be required.

Department Preferences

  • Knowledge: General knowledge of policies and programs utilized in the operation of a health care facility
  • Analyzing and presenting data in graphical format
  • Skill: Excellent computer skills, rapid and effective navigation of electronic health records including Epic, accurate and reliable abstraction and interpretation of clinical data from the health record and other relevant sources according to program specifications, use of Excel and other software to organize and track data, access and entry of data into databases including online quality and regulatory platforms, creation of effective data displays
  • Ability: ability to assimilate and analyze data, to recommend action based on analytical findings, to manage time in order to abstract and analyze data in a timely fashion according to required schedule, and to assist in the solution of complex problems in health care administration and management.
  • Include a list of required skills for the role.
  • Additional Skills: ICARE, excellent communication, problem solving, multidisciplinary collaboration

Please be advised that proof of Covid-19 vaccination is required prior to hire.