Company: Memorial Health
Posted on: November 17, 2021
Utilizes clinical and nursing knowledge of documentation
requirements to improve overall quality and completeness of
clinical documentation of patient records. Works collaboratively
with physicians to ensure clinical information in medical record is
present and accurate to guarantee the appropriate clinical severity
is captured for the level of services rendered.
To perform this job successfully, an individual must be able to
perform each essential duty satisfactorily. The requirements listed
below are representative of the knowledge, skill, and/or ability
- Knowledge of Clinical Documentation Systems.
- Working knowledge of DRG and/or APC assignment.
- Extensive knowledge of pathophysiology, clinical indicators,
and medical/surgical nursing.
- Excellent analysis, communication, and decision-making
- Ability to work as team member. Responsibilities
- Facilitates appropriate clinical documentation to support the
appropriate diagnosis and procedure coding and to ensure the level
of service rendered to all patients is recorded.
- Follows documentation improvement processes for conducing
medical record reviews and meets goals related to appropriate
- Assigns a working DRG using coding rules and guidelines.
- Works with physicians on assigned patient care units to clarify
documentation in the medical record.
- Queries physicians on a concurrent and retroactive basis to
ensure documentation appears on the medical prior to billing.
- Reviews clinical issues with the Health Information Management
(HIM) coding staff to assign a working DRG.
- Identifies missed opportunities related to clinical
documentation and coding guidelines and works to ensure accuracy
for future coding.
- Works with Coders, Coding Team Leads and/or Coding Supervisor
to resolve differences between CDI and Coding Staff.
- Coordinates documentation improvement processes with physicians
and HIM coding staff to identify those diagnoses that impact
severity of illness indicators for each patient.
- Collaborates with the multidisciplinary team to reflect quality
- Identifies clinical indicators that suggest a need for
- Adheres to hospital standards to promote a cooperative work
environment by utilizing communication skills, interpersonal
relationships, and team building.
- Contributes to the overall quality of services.
- Assumes responsibility for keeping informed about changes in
policies and procedures.
- Communicates information effectively.
- Demonstrates responsibility for personal development by
participating in continuing education offerings.
- Maintains competence related to DRG assignment, documentation
requirements and coding guidelines.
- Perform other job-related duties as required . Associated
topics: care physician, family, family medicine physician,
physician, physician md, physician md do, practice physician,
practitioner, primary, urgent
Keywords: Memorial Health, Decatur , CDI Specialist, Other , Decatur, Illinois
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