Make Your Dream Job Your Reality
- Performs concurrent and retrospective reviews of the medical record utilizing evidence-based knowledge, protocols and criteria.
- Works closely with the medical staff and other healthcare team member to help identify potential gaps in physician documentation and ensuring appropriate reimbursement is received for the level of service rendered to all patients.
- Utilizes research, analytic data and observations to provide recommendations to improve the overall quality and completeness of clinical documentation.
- Establishes cooperative and multidisciplinary relationships with physicians, coding staff and other health team members.
- Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs and successful problem resolution.
- Demonstrates familiarity with MS-DRG/APR-DRG’s and Inpatient Prospective Payment System (IPPS).
- Completes initial reviews of patient records to evaluate documentation to identify and assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate assignment of the working DRG, risk of mortality, and severity of illness.
- Completes follow-up reviews.
- Reviews a minimum of standard charts per day as directed.