Short Description
- Uses clinical expertise to review patient medical records and ensure that the documentation accurately reflects the patient’s diagnosis, treatments and severity of illness. This role bridges the gap between healthcare providers and coding professionals, ensuring that medical records are complete, compliant, and support proper reimbursement.
- Concurrently review inpatient medical records for clear consistent, concise, legible and accurate documentation to reflect the patient’s severity of illness and intensity of services.
- Generate and utilize queries to clarify physician documentation whenever there is conflicting, ambiguous or incomplete information in the medical record regarding any significant reportable condition or procedure.
- Complete analysis of clinical information to identify gaps in clinical documentation. To “bridge the gap” utilize the physician advisor for clarification of clinical presentation.
- Collaboratively work with HIM Leadership, Coders, Coding Quality Educators/Reviewers and peers to improve accuracy of final DRG.
- Collaborate and provide educational support to physicians, nurses and ancillary staff to facilitate modifications of clinical documentation processes that promote documentation improvement.
- Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients.
- Provide clinical review of cases denied for medical necessity by auditing agencies. Using knowledge of medical necessity criteria assist physician advisor in collecting pertinent information to support an appeal.
Experience Required
3-5 years of experience required.
Education Requirements
- High School/GED Required
- Bachelor's Degree Required
- Bachelor's of Science in Nursing preferred
License/Certification Requirements
- Certified Clinical Documentation Specialist Certification preferred
- Certified Documentation Improvement Practitioner preferred
- Registered Nurse, any state, preferred
Special Requirements
Professional team player, able to communicate well with others on all levels required.
Salary Min ($)USD $34.00
Salary Max ($)USD $56.00
