– This position is responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation.
– This position facilitates modifications to clinical documentation through concurrent interaction with physicians (verbally and electronically) and other members of the health care team.
– The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding.
– Graduate of an accredited school of professional nursing or Graduate of an accredited School of Medicine Licenses/Certifications:
– RN or MD required
– CCDS or CDIP preferred
– Three (3) years of clinical experience in an acute care setting required, five (5) years preferred
– Critical care experience or knowledge preferred
– Working clinical knowledge of many areas of medicine
– Detail oriented, with excellent analytical thinking, and problem solving skills
– Ability to assess, evaluate and teach with effective oral and written communication skills
– Proficient in utilizing EMR documentation platforms
– Strong interpersonal skills and ability to interact in a positive fashion with physicians, CDI team members and other employees
– Responsible for the day-to-day review and evaluation of electronic documentation by the medical staff and healthcare team in accordance with CDI Department Policies and Procedures and CMS rules and regulations for documentation and coding.
– Efficiently and productively utilizes the hospital’s EMR and designated CDI/Coding software systems to: review medical records, identify all opportunities for improved physician and hospital outcomes, and query physicians electronically/verbally, in order to obtain needed documentation prior to records being coded.
– Responsible for the accurate capture of record review and query data, and calculation of accurate documentation performance measures to ensure report integrity/accuracy for leadership, medical staff, and other departments.
– Communicates with physicians, coders, and other healthcare team members to facilitate comprehensive medical record documentation of diagnoses evaluated/treated, and procedures performed.
– Identifies opportunities and trends variances to strategically direct provider education, and improve provider documentation.
– Assists in the development of physician education to promote complete and accurate clinical documentation and correct negative trends via tip sheets, tip cards, meeting handouts, or PowerPoint presentations.
– Researches literature on ACDIS website and stays abreast of annual changes to CMS/Coding rules and regulations, and Quarterly Coding Clinics, incorporating changes into daily practice for overall documentation improvement.
– Conferences individually with key physicians to review regulations and coaches them to improve their documentation so it more accurately reflects the intensity of service, severity of illness, and risk of mortality of their patients, in order for coding to capture the most accurate ICD codes, DRG, SOI, and ROM designation.
– Provides education to all internal customers related to compliance, coding, and clinical documentation issues/opportunities and acts as an internal consultant to these customers, when additional documentation is needed to assign the correct DRG, SOI or ROM.
– Attends various hospital service line meetings, reviewing outcome information/reports, auditing records and educating physicians on service line specific improvement opportunities.
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