Job Summary: 

• Complete initial review and necessary follow-up on patients' records by analyzing clinical information to identify potential gaps in provider documentation
• Formulate appropriate clinical documentation clarifications and educate key healthcare professionals to ensure appropriate enhancements are ongoing
• Collaborate with healthcare team to ensure physician queries are resolved before discharge
• Identify ongoing documentation improvement opportunities
• Assist with the preparation and presentation of clinical documentation monitoring/trending reports for review
• Perform thorough, methodical chart reviews according to department review process.
• Comprehensively reviews all physician and clinical documentation to identify potential opportunities for documentation improvement.
• Compose clinical documentation queries that are compliant with CMS and AHIMA guidelines
• Be a part of the multi-disciplinary team that facilitates in the overall quality, completeness and accuracy of medical record documentation. 
• Conduct ongoing daily and retrospective documentation reviews and aggregate data analysis to improve medical clinical documentation, substantiate the medical necessity of services, and facilitate accurate coding
• Communicate effectively with physicians and other members of the interdisciplinary team to establish appropriate levels of severity of illness and risk of mortality, and to clarify accurate documentation of principal diagnosis, co-morbid conditions, complications and procedures in the medical record.

Skills on Resume: 

• Clinical Knowledge (Hard Skills)
• Analytical Skills (Hard Skills)
• Communication Skills (Soft Skills)
• Documentation Expertise (Hard Skills)
• Team Collaboration (Soft Skills)
• Data Analysis (Hard Skills)
• Quality Improvement (Hard Skills)
• Regulatory Compliance (Hard Skills)

Job Summary: 

• Serves as a resource for appropriate clinical documentation.
• Identifies learning opportunities for healthcare providers.
• Assist in developing educational tools for clinical and non-clinical staff
• Collaborate with the coding staff to ensure the accuracy of documentation and coding that are compliant with State and Federal requirements and standards
• Review patient health records for accurate and complete documentation of all relevant diagnoses, procedures, and ancillary treatments.
• Train providers on how to facilitate complete discharge summaries in promotion of post-acute care and facilitation of orderly handoff to patient's primary care physician.
• Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication and quality outcomes.
• Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider participation.
• Educate providers on how to document continuity and specificity of clinical documentation throughout the record, including progress notes reflective of the progress of the patient.
• Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
• Completes monthly reconciliation of CDS coded records, collaborating with the HIM coding team to ensure the accuracy of the medical records and resolution of any discrepancies you may find during reconciliation.

Skills on Resume: 

• Clinical Documentation Expertise (Hard Skills)
• Educational Development (Hard Skills)
• Coding Compliance Collaboration (Hard Skills)
• Health Record Review (Hard Skills)
• Provider Training (Hard Skills)
• Quality Management (Hard Skills)
• Physician Education and Communication (Soft Skills)
• Documentation Improvement (Hard Skills)

Job Summary: 

• Assign the working DRG based on coding guidelines/regulations issued by AHA (Coding Clinic), CMS, and AHIMA.
• Maintains professional competency by keeping abreast of new coding issues and guidelines. 
• Reviews professional coding literature regularly.
• Interprets clinical information in medical records, and evaluates medications, vital signs, surgical outcomes, etc. to identify potential diagnoses.
• Identifies opportunities for education to improve medical record documentation for severity of illness.
• Contributes to and participates in educational efforts and activities.
• Work closely with the physicians to ensure high-quality documentation that supports the accurate representation of the care provided to the patient as reflected through MS-DRG assignment, case mix index, severity of illness, risk of mortality, quality measures and reimbursement rules. 
• Works collaboratively with medical, nursing and ancillary staff and case managers to improve the quality of medical record documentation to assure appropriate DRG classification to accurately reflect severity of illness and risk of mortality.
• Performs initial reviews utilizing screening guidelines and appropriately schedules follow-up reviews based on judgment of clinical findings, completeness of documentation and departmental review standards.
• Performs concurrent reviews of selected inpatient admissions to include assignment of working DRG, identifying complications and co-morbid conditions, specific co-existing conditions, and following up with a physician, physician’s assistant, or nurse practitioner responsible for the care of a patient for clarification of clinical significance and appropriate documentation.

Skills on Resume: 

• Knowledge of Coding Guidelines and Regulations (Hard Skills)
• Continuous Learning and Professional Development (Soft Skills)
• Clinical Information Interpretation (Hard Skills)
• Educational Initiatives (Soft Skills)
• Collaboration with Physicians (Soft Skills)
• Collaborative Approach (Soft Skills)
• Review and Evaluation Skills (Hard Skills)
• Communication and Clarification (Soft Skills)

Job Summary: 

• Review health records to identify gaps within clinical documentation
• Work closely with team members and physicians to communicate documentation issues
• Review medical records, identify, track and resolve documentation queries
• Requests clarification of existing documentation that most accurately reflects patient severity.
• Communicates cooperatively daily with coding specialists and case managers regarding mutual cases.
• Meets with lead physician advisor, and ensures compliance with policies and procedures
• Fulfills continuing education requirements to maintain credential/license status.
• Communicates effectively with medical staff and Data Quality Specialists and Coding Manager to acquire, interpret, and transmit accurate diagnostic and procedure information for billing.
• Participates in seminars, in-service/educational efforts and activities sponsored by professional associations at the local, state, and national levels. 
• Communicate verbally, via email, or in writing with a physician, physician’s assistant, or nurse practitioner to obtain/clarify more specific principle diagnoses or co-morbidities and complications. 
• Provide active, concurrent as well as retrospective reviews of clinical documentation, providing feedback, and educating clinical care providers on how to improve the documentation of all conditions, treatments and care plans within the health record to accurately reflect the condition of the patient and promote patient care. 

Skills on Resume: 

• Clinical Documentation Review (Hard Skills)
• Communication Skills (Soft Skills)
• Query Resolution (Hard Skills)
• Medical Terminology (Hard Skills)
• Collaboration (Soft Skills)
• Compliance Management (Hard Skills)
• Continuing Education (Hard Skills)
• Educational Support (Soft Skills)