Stephanie Baksh RN, RHIA, CCDS, CDIP, CCS
Franklin Square,NY
Summary
Detail oriented Clinical Documentation Specialist with over 15 years of experience in inpatient medical coding, DRG validation, and clinical documentation integrity. Skilled at bridging the gap between clinical care, documentation, and coding to ensure regulatory compliance, optimize reimbursement, and improve provider documentation practices. A quick and adaptable learner, demonstrated by career advancement, now seeking to return to my passion in a role focused on clinical documentation improvement.
Overview
22
22
years of professional experience
1
1
Certification
Work History
Associate Director, Clinical Documentation Integrity
NYU Langone Health
New York, NY
01.2023 - Current
- Query providers to ensure accurate and complete documentation to allow for the capture of ICD-10-CM/PCS codes to reflect appropriate DRG assignment.
- Deliver provider education to promote best practices in clinical documentation.
- Collaborate closely with the coding team to gather insights and provide actionable takeaways to the CDI team, supporting targeted education and improved practices.
- Work closely with CDI physician advisors to address documentation-related questions and clarify their impact on coding and reporting.
- Review clinical documentation for quality and important measures, such as PSI, HACs, Vizient, readmissions, and HCC.
Assistant Director, Clinical Documentation Integrity
NYU Langone Health
New York, NY
01.2020 - 01.2023
- Collaborated with physicians, coders, and CDI team members to clarify documentation and resolve coding discrepancies.
- Oversaw reviews of Vizient, PSI/HAC, readmission data, and special projects to improve performance and maintain compliance system-wide.
- Escalated unresolved queries by following up with providers on aged accounts to ensure timely responses and accurate documentation.
- Participate in multidisciplinary meetings to provide CDI perspectives, ensuring alignment with organizational objectives and fostering cross-functional collaboration.
Clinical Documentation Specialist – Coding Liaison
NYU Langone Health
New York, NY
01.2014 - 01.2019
- Worked closely with the CDI, coding, and quality teams to resolve documentation and coding issues.
- Used CMS guidelines and AHA Coding Clinics to ensure correct MS-DRG and APR-DRG assignment.
- Wrote clear and compliant physician queries to clarify documentation and improve the capture of severity of illness.
- Performed audits to ensure coding accuracy, query appropriateness, and to identify missed opportunities affecting DRG assignment.
- Reviewed PSI and HAC cases to support accurate reporting and compliance.
Adjunct Instructor, ICD-10-PCS
NYU School of Professional Studies
01.2017 - 12.2017
- Taught ICD-10-PCS structure, conventions, and root operations to prepare students for accurate procedural coding.
DRG Validator/Auditor
Jzanus Consulting
01.2011 - 01.2015
- Reviewed inpatient medical records to ensure the accuracy of ICD-9/10-CM and PCS coding, and validated DRG assignments to support appropriate reimbursement.
- Provided education and feedback to coding and CDI teams based on audit findings to enhance documentation quality and improve capture rates.
Registered Nurse, Telemetry
North Shore University Hospital
Manhasset, NY
01.2010 - 01.2011
- Performed nursing assessments, provided skilled care, and monitored cardiac patients on telemetry.
Inpatient Medical Coder
North Shore LIJ / Cohen Children’s Hospital
New Hyde Park, NY
01.2005 - 01.2010
- Assigned ICD-9 diagnosis and procedure codes to inpatient records including adult and pediatric cases.
- Queried providers for documentation for accurate and complete coding.
Health Information Management Coordinator
North Shore LIJ
New Hyde Park, NY
01.2004 - 01.2005
- Ensured completion of medical records, including operative reports, labs, progress notes, and discharge summaries.
- Corrected documentation gaps to support compliance and workflow.
Education
Bachelor of Science - Nursing
Molloy College
Rockville Centre, NYBachelor of Science - Health Information Management
C.W. Post/Long Island University
Brookville, NYSkills
- CDI Software (Epic, 3M/Solventum)
- Critical thinking
- Verbal and written communication
- ICD-10-CM/PCS
- MS DRG and APR DRG assignment
- Severity of illness, risk of mortality
- Documentation auditing
- Provider education
- Quality improvement
- Regulatory guidelines (CMS, AHA Coding Clinic)
- PSI/HAC/HCCs reviews
Certification
- Registered Nurse (RN)
- Certified Clinical Documentation Specialist (CCDS)
- Clinical Documentation Improvement Practitioner (CDIP)
- Certified Coding Specialist (CCS)
- Registered Health Information Administrator (RHIA)
Timeline
Associate Director, Clinical Documentation Integrity
NYU Langone Health
01.2023 - Current
Assistant Director, Clinical Documentation Integrity
NYU Langone Health
01.2020 - 01.2023
Adjunct Instructor, ICD-10-PCS
NYU School of Professional Studies
01.2017 - 12.2017
Clinical Documentation Specialist – Coding Liaison
NYU Langone Health
01.2014 - 01.2019
DRG Validator/Auditor
Jzanus Consulting
01.2011 - 01.2015
Registered Nurse, Telemetry
North Shore University Hospital
01.2010 - 01.2011
Inpatient Medical Coder
North Shore LIJ / Cohen Children’s Hospital
01.2005 - 01.2010
Health Information Management Coordinator
North Shore LIJ
01.2004 - 01.2005
Bachelor of Science - Nursing
Molloy College
Bachelor of Science - Health Information Management
C.W. Post/Long Island University
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