1. Performs Medical Record Chart reviews, utilizing EMR and department encoder and CDI software.
2. Conducts successful interventions related to documentation improvement and ensures follow through with all recommendations.
3. Responsible for reviewing medical records to facilitate the accurate representation of the severity of illness.
4. Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
5. Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends.
6. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
7. Assigns a working APR-DRG and severity level using coding rules and guidelines with follow up reviews as required by LOS standards.
8. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
9. Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record.
10. Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
11. Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM APR-DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a working DRG.
12. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing.
13. Utilizes software systems (including APR-DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation. Maintains integrity of data collection.
14. Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.
Knowledge & Skills Required:
1. Work requires the knowledge of theories, principles, and concepts typically acquired through completion of a Bachelor’s Degree in Nursing. Minimum of five years recent, broad-based clinical experience in an inpatient pediatric setting required.
2. Experienced working with 3M 360, Allscripts, Epic and or Optum 360.
Certification, Registration or License Required:
1. Registered Nurse, Coders, or MD-equivalent.
2. Credentialed as CDIP, CCDS.
3. CCS Certification is a plus.