Job Description
Description
1. Completes initial review(s) of patient records within 48 hours of admission for a
specified patient population.
2. Evaluate documentation to assign the principal diagnosis, pertinent secondary
diagnoses, and procedures for accurate DRG assignment, risk of mortality and
severity of illness and initiate a review worksheet.
3. Conducts follow-up reviews of patients to support and assign a working or final DRG
assignment upon patient discharge.
4. Queries physicians regarding missing, unclear or conflicting health record
documentation by requesting and obtaining additional documentation within the
health record.
5. Educates physicians and key healthcare providers regarding clinical documentation
improvement and the need for accurate and complete documentation in the health
record or documentation and to resolve physician queries prior to patient discharge.
6. Assists with preparation and presentation of clinical documentation
monitoring/trending reports for review with physicians and hospital leadership to
identify opportunities for improvement and facilitates change processes required to
capture needed documentation.
7. Collaborates with case managers, nursing staff and other ancillary staff regarding
interaction with physicians.
8. Educates members of the patient care team regarding specific documentation
needs, reporting and reimbursement issues identified through daily documentation
reviews and aggregate data analysis.
9. Partners with the coding professionals to ensure accuracy of diagnostic, procedural
data, completeness of supporting documentation to determine a working and final
DRG, severity of illness, and/or risk of mortality.
10. Other duties as assigned.
Requirements:
Bachelor degree in healthcare nursing, medical or health information management.
CCS, CDIP, CDIS, RN, MD, RHIT, or RHIA required.
Previous experience as a CDI in an acute care facility.
Qualifications
Education
Required
Bachelors or better.
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