PURPOSE OF JOB: Obtains appropriate Clinical Documentation through extensive interaction with physicians, nursing staff, other patient care givers, and Health Information Management coding staff to ensure compliant, and robust Clinical Documentation needed to support correct code assignment. Applies coding guidelines to ensure optimal reimbursement is received for the level of services rendered. Reviews physician documentation to optimize clinical information which is utilized in profiling and reporting outcomes to insure documentation integrity and accuracy. On an ongoing basis, educates all members of the patient care team on Clinical Documentation guidelines.
1. Demonstrates knowledge of Clinical Documentation requirements and guidelines in accordance with Coding Clinic, professional CDI publications, Core Measures and other hospital initiatives as required.
2. Requires excellent communication skills, high level critical and analytical thinking skills, and problem solving in addition to good verbal and written communication and able to work independently.
3. Improves the overall quality and completeness of Clinical Documentation by performing admission/continued stay reviews using Clinical Documentation guidelines.
4. Updates CDR2 Computer System to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnosis as well as, conducts follow up reviews of compliant documentation to ensure points clarification with the physician have been recorded in the patient's chart.
5. Enters and updates diagnoses in Meditech's Problem List per Department procedure.
6. Identifies redundant, inconsistent or nonsensical information in the Physician Progress Notes and notifies appropriate physician representative of finding.
7. Queries physicians/patient care providers via paper queries entered in Meditech or via Tiger Text to provide compliant documentation necessary to support clinical care and accurate DRG/APR-DRG grouping as well as maximized SOI and ROM scores
8. Performs other duties as assigned.