Reviews medical records to facilitate the accurate representation of the severity of illnesses and risk of mortality by improving the quality of physicians� clinical documentation. This position involves extensive record review, interaction with physicians, residents, Advanced Practice Nurses, HIM professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Improvement Process is one of the key responsibilities of this role.
1. Completes initial reviews of patient records within 24 to 48 hours of admission. Collaborates with clinical staff to identify principal diagnosis options, secondary diagnoses and procedures, and to assign working DRGs for at least 85% of identified populations.
2. Utilizes inpatient admission criteria to assign only diagnoses that meet acute care criteria.
3. Conducts follow-up reviews of patients every 2 to 3 days. Identifies need to clarify documentation in records, and utilizes strong communication skills with clinical staff utilizing appropriate tools to capture needed documentation.
4. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health records when needed.
5. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation to resolve physician queries prior to patient discharge.
6. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
7. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identifies through daily and respective documentation reviews and aggregates data analysis.
8. Participates in analysis and trending of statistical data for specified patient populations to identify opportunities for improvement. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
9. Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
10. Assists in the development of APR/DRG/query response physician reports.
11. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
12. Facilitates change processes required to capture needed documentation.
13. Assists in the appeal process resulting from third-party reviews.
14. Performs job functions adhering to service principles with customer service focus of innovation, service excellence and teamwork to provide the highest quality care and service to our patients, families, co-workers and others.
1. Bachelor�s degree in Nursing, Healthcare Administration or related field required. A combination of education and/or experience may be considered in lieu of the degree when the experience is directly related to the functions of the role.
2. A minimum of 5 years of experience in a healthcare setting. Prior acute care nursing experience strongly preferred.
3. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes strongly preferred.
4. Ability to communicate with all levels of clinical staff.
5. Demonstrated understanding and ability to recognize complex diagnoses, clinical complications and co-morbidities.
6. Ability to work independently in a time-oriented environment.
7. Excellent written and verbal communications skills as well as critical thinking skills.
8. Working knowledge of reimbursement systems and coding structures preferred.
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