Job Summary: 

• Act as a documentation regulatory expert by remaining up to date with federal, state, and organizational guidelines related to documentation
• Conducts regular and ad hoc documentation audits to identify errors and facilitate improvement.
• Cross references managed care contracts for required documentation for payment and report discrepancies with a corrective action plan.
• Keeps abreast of all organizational processes and Cerner updates, in addition to pertinent state and federal regulatory updates that may affect documentation requirements.
• Researches the industry and state-specific regulatory and payor documentation policy changes on time.
• Performs risk assessments and gap analysis of the clinical documentation processes and policies.
• Flags and reports discovered documentation and/or workflow deficiencies against payer and regulatory guidelines to ensure supporting documentation stays current to minimize risk and ensure
• Contributes with a focused examination of regulations requiring attention and aids in developing strategies to address these.
• Acts as a resource, providing professional guidance for department leaders and staff.
• Acts as a liaison to regulatory/compliance and patient financial services to aid in resolving high-risk documentation-related issues including patient financial complaints.

Skills on Resume: 

• Regulatory Expertise (Hard Skills)
• Documentation Audits (Hard Skills)
• Contract Cross-Referencing (Hard Skills)
• Knowledge Management (Hard Skills)
• Policy Research (Hard Skills)
• Risk Assessment and Gap Analysis (Hard Skills)
• Compliance Reporting (Hard Skills)
• Strategic Development (Hard Skills)

Job Summary: 

• Facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation.
• Strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients.
• Serving as a resource to all members of the health care team on documentation guidelines
• Improves overall quality and completeness of clinical documentation by performing admission/continued stay reviews.
• Conduct timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider.
• Utilize coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation user for measuring and reporting physician and hospital outcomes.
• Queries physicians on the specificity of procedures performed and diagnosis based on accepted coding guidelines and clinical expertise.
• Tracks and trends specific opportunities for improvement through the query process and conducts educational sessions with physicians and other healthcare team members on documentation requirements.
• Reviews clinical issues with physician advisors and participates in data collection for performance measures.
• Current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic, and ICD-9-CM Official Guidelines for Coding and Reporting.

Skills on Resume: 

• Clinical Documentation Improvement (Hard Skills)
• Documentation Guidelines Expertise (Hard Skills)
• Review and Assessment (Hard Skills)
• Coding and Clinical Expertise (Hard Skills)
• Query Management (Hard Skills)
• Educational Outreach (Soft Skills)
• Performance Measures and Data Collection (Hard Skills)
• Regulatory Compliance (Hard Skills)

Job Summary: 

• Responsible for clinical documentation analysis of the medical record, documentation completeness, coding accuracy and compliance in either electronic or hard copy form as designated.
• Perform initial case reviews and appropriate follow-up reviews based on judgment of the clinical course of events.
• Perform concurrent reviews of the medical record for inpatient admissions to include assignments of DRG, identifying complication and co-morbid conditions and specific co-existing conditions.
• Document findings electronically, or hard copy worksheets if applicable, and record any identified key quality indicators, as appropriate.
• Work collaboratively with the Medical Staff, Nursing Staff and other patient caregivers to improve the quality of chart documentation to accurately reflect services provided.
• Educate physicians on documentation requirements to support medical necessity for hospital and physician billing.
• Present an accurate hospital and physician's profile, all diagnoses and procedures must be documented in the medical record and must properly reflect the level of services provided.
• Timely communication with assigned service line physicians as assigned.
• Interpret clinical information in the medical record, ordered interventions, lab and test results, etc., and queries if necessary for supporting documentation in progress notes, consultations, history and physicals, etc.
• Initiate communication with physicians, and providers, verbally or utilizing the appropriate prompter/query tools, to obtain more specific principal diagnoses or co-morbidities and complications. 

Skills on Resume: 

• Clinical Documentation Analysis (Hard Skills)
• Case Review and Follow-up (Hard Skills)
• DRG Assignment and Coding (Hard Skills)
• Quality Indicators Recording (Hard Skills)
• Collaboration Skills (Soft Skills)
• Physician Education (Soft Skills)
• Medical Record Accuracy (Hard Skills)
• Effective Communication (Soft Skills)

Job Summary: 

• Solicit clarification of existing documentation in the medical record that supports patient severity of illness.
• Act as an expert clinical resource for the HIM Coding team, work collaboratively to identify areas for clarification of documentation in the medical record that meets regulatory requirements to accurately reflect patient severity of illness and services provided.
• Coordinate with the HIM Coding team related to coding guideline requirements for clinical documentation.
• Collaborate with the HIM Coding team to provide information and education to physicians and other providers not responding to prompters/ queries on documentation requirements.
• Maintain and disseminate up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area.
• Maintain up-to-date working knowledge of all PHS coding and documentation IT applications.
• Maintain current knowledge of Nursing Practice through seminars, workshops, publications, etc.
• Conduct training classes in areas of coding, documentation and compliance for physicians and other providers.
• Serve as a liaison to other departments, providing clinical expertise and consultation.
• Utilizes monitoring tools to track defined measures for the progress of documentation accuracy
• Maintain accurate, detailed and organized records.
• Maintain positive interdepartmental relations and develop effective collegial collaboration.

Skills on Resume: 

• Clinical Documentation Improvement (Hard Skills)
• Clinical Expertise (Hard Skills)
• Coordination and Collaboration (Hard Skills)
• Regulatory Knowledge (Hard Skills)
• IT Proficiency (Hard Skills)
• Training and Education (Hard Skills)
• Communication and Liaison (Soft Skills)
• Monitoring and Recordkeeping (Hard Skills)

Job Summary: 

• Set up and maintain filing systems (ex. Trial Master File and electronic filing systems) following SOPs and study specific guidelines, and within specific timelines.
• Receive all study documentation from the Project Team, client, site, or Clinical Research Associate.
• Contribute to the quality of the TMF by performing quality control checks of the filing for TMF documents
• Prepare, distribute, track, scan, and file essential clinical trial documentation.
• Using a study training matrix, maintain study-specific training documentation for internal project team members and escalate non-compliance
• Assist with ethics and regulatory submissions for clinical trials and keep track of submissions and approvals.
• Assist Project Managers and Clinical Research Associates with the creation and maintenance of tracking tools and study materials.
• Arrange and provide general administrative support in the organization of Investigator meetings, study team meetings, special projects
• Prepare and distribute agenda and minutes for the study team
• Assemble and ship the Investigator Site File to investigative sites.

Skills on Resume: 

• Filing System Management (Hard Skills)
• Document Handling (Hard Skills)
• Quality Control (Hard Skills)
• Document Management (Hard Skills)
• Training Documentation (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Administrative Support (Soft Skills)
• Meeting Coordination (Soft Skills)

Job Summary: 

• Assist in the preparation of Health Canada submission packages (CTA/CTA-A/Notifications).
• Assist in the submission of CTA, amendments, ongoing reporting, ADR, SADR and end-of-trial notifications to regulatory authorities.
• Coordinate archiving of study documentation.
• Participate in the development and/or review of SOPs, supporting documents, policies and work instructions.
• Maintain documents for non-conformance, CAPA and audit observations.
• Assist in the preparation of regulatory inspections.
• Support internal and external audits including preparation, follow-up and tracking of action items.
• Develop, modify and utilize tools to track compliance issues and audit findings.
• Assist with identifying workflow and modification of same to improve efficiencies.
• Track the completion of audit response activities to ensure timely resolution and the appropriate documentation is maintained in audit files.

Skills on Resume: 

• Regulatory Submissions Management (Hard Skills)
• Documentation Management (Hard Skills)
• Quality Management Systems (QMS) (Hard Skills)
• SOP and Policy Development (Hard Skills)
• Regulatory Inspections Preparation (Hard Skills)
• Audit Support (Hard Skills)
• Compliance Tracking Tools (Hard Skills)
• Process Improvement (Soft Skills)

Job Summary: 

• Communicate with physicians to ensure accurate and complete documentation are in medical records.
• Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation ensuring they reflect clinical treatment, decisions, and diagnoses for inpatients.
• Demonstrate an understanding of complications, co-morbidities, the severity of illness, the risk of mortality, case mix, secondary diagnosis, and the impact of procedures on the final DRG
• Identify patterns, trends, variances, and opportunities to improve the documentation review and process.
• Participate in departmental and hospital committees and assigned Task Force groups.
• Provide or coordinate education to all internal customers related to compliance, coding, and clinical documentation issues.
• Seek out educational resources to enhance clinical and coding knowledge, take advantage of learning opportunities.
• Prepares and presents educational programs using adult learning principles identified improvement needs as indicated. 
• Assist with departmental policy review, revision, and development. 
• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.

Skills on Resume: 

• Clinical Communication Skills (Hard Skills)
• Clinical Documentation Improvement (Hard Skills)
• Data Analysis (Hard Skills)
• Committee Participation (Hard Skills)
• Education and Training (Hard Skills)
• Continuous Learning (Hard Skills)
• Policy Review and Development (Hard Skills)
• Reporting and Goal Monitoring (Hard Skills)

Job Summary: 

• Utilizes paper or electronic tools and reports to identify and prioritize case reviews, follow-up reviews and outstanding queries.
• Utilizes critical thinking skills to perform concurrent review of clinical documentation in the medical record.
• Analyze the patient's current clinical status, treatment plan and past medical history to identify potential gaps in physician documentation.
• Identifies the principal diagnosis and all secondary conditions, co-morbidities, complications and procedures that have been documented in the medical record.
• Evaluate anchor visits for each diagnosis that could potentially affect risk score calculation.
• Queries the physician, mid-level clinicians and other clinicians for clarification and to obtain accurate and complete documentation
• Follow commercial and governmental coding regulations as determined by the payer
• Adheres to AHIMA guidelines for effective, compliant query writing.
• Regular queries to Claims and Clinical data and appropriate follow-up interventions
• Applies knowledge/skills regarding coding conventions, coding guidelines and coding clinics when reviewing the medical record.
• Adheres to the Clinical Documentation program's established workflow and processes.
• Performs retrospective medical record reviews
• Access claims and clinical data to identify high and low network performers
• Focus on commercial products, and assist with Medicare Advantage preparation and planning

Skills on Resume: 

• Clinical Documentation Review (Hard Skills)
• Critical Thinking (Hard Skills)
• Medical Coding Compliance (Hard Skills)
• Query Management (Hard Skills)
• Risk Adjustment (Hard Skills)
• Coding Knowledge (Hard Skills)
• Claims and Clinical Data Analysis (Hard Skills)
• Workflow Adherence (Hard Skills)

Job Summary: 

• Interact with IT teams from each participating organization to understand and identify EHR capabilities and coding tools for HCC and MRA coding
• Works collaboratively with the coding professionals to obtain documentation of diagnoses, co-morbidities and procedures
• Consult with coding professionals for clarification regarding coding conventions and guidelines.
• Works collaboratively with the Medical Director when escalation of cases is required and develops and implements ongoing physician education programs.
• Collaborates with physicians, mid-level residents/interns, mid-level clinicians and other clinicians to accurately identify principal diagnosis options, secondary diagnoses and procedures.
• Serves as a resource to physicians, mid-level clinicians and other clinicians regarding clinical documentation, severity of illness and risk of mortality.
• Approaches and responds to conflict constructively, with a focus on problem-solving for a collaborative solution/resolution.
• Provides formal and informal feedback and training to physicians, mid-level clinicians and other clinicians concerning clinical documentation excellence and the impact of documentation on coding accuracy, healthcare profiling and correct reimbursement.
• Work collaboratively with subnetwork documentation and coding specialists
• Demonstrates competency with the utilization of all necessary software and information systems necessary to conduct clinical documentation activities.
• Identifies opportunities during the reconciliation process for second-level review and follows up with coding professionals to make sure appropriate documentation is present for accurate coding.
• Generate and present appropriate reports
• Interprets data monitoring reports and identifies areas of focus for documentation improvement through analysis of monthly data.
• Maintains professional integrity and confidentiality of information following applicable policies, procedures, and state and federal requirements.

Skills on Resume: 

• Understanding EHR Capabilities (Hard Skills)
• Collaboration with Coding Professionals (Hard Skills)
• Knowledge of Coding Conventions (Hard Skills)
• Physician Collaboration (Hard Skills)
• Physician Education Programs (Hard Skills)
• Clinical Documentation Excellence (Hard Skills)
• Conflict Resolution (Soft Skills)
• Data Analysis and Reporting (Hard Skills)

Job Summary: 

• Participating in the development and design of improvement activities and standards
• Participating in the design of data collection tools and procedures, including planning, measuring and assessing the effect of improvement activities
• Analyzing, collection and tabulation go appropriate primary and secondary sources of importation.
• Displaying data in a meaningful and useful format.
• Attending meetings to assist in the interpretation of quality improvement studies
• Utilizes advanced knowledge of functional health patterns physiology, pathophysiology, and psycho-sociology in documentation efforts and other projects related to Outcomes Management.
• Serves as a resource for clinical documentation and provides support to associates regarding complex patient issues and the impact on clinical documentation needs
• Provides consultative services to medical and nursing staff related to documentation and core clinical indicators
• Establishes collaborative practice and maintains open communication with other nursing personnel, physicians and health care professionals regarding clinical documentation.
• Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient’s chart.

Skills on Resume: 

• Quality Improvement Methodologies (Hard Skills)
• Data Collection and Analysis (Hard Skills)
• Data Visualization (Hard Skills)
• Interpretation of Quality Improvement Studies (Hard Skills)
• Clinical Knowledge (Hard Skills)
• Clinical Documentation Support (Hard Skills)
• Consultative Services (Soft Skills)
• Documentation Review (Soft Skills)