Responsible for extensive collaboration with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded.
In this role, you will facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, case managers, nursing staff, other patient caregivers, and medical records coding staff, to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all patients with a DRG based payer.
Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services; include facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality.
The Clinical Documentation Specialist will maintain proficiency in use of Clinical Documentation Improvement (CDI) applications and all application software used to code and assign working MS-DRG, APR-DRG, SOI, ROM.
In this role, you will responsible for improving the overall quality and completeness of the clinical documentation in the medical records to reflect the severity of illness, clinical treatment, decisions, and diagnoses of patients.