Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided. Responsible for concurrent inpatient medical record reviews for Medicare, Medicaid and all commercial payers. Generates queries and have follow up discussions with physicians for clarification of ambiguous or conflicting documentation.
- Facilitates modifications to clinical documentation supporting appropriate reimbursement is received for the level of service rendered to all patients.
- Demonstrates knowledge of payor issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
- Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation (CD) guidelines.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and Hospital outcomes.
- Assists in screening process, making referrals, interacting with medical staff, and various departments to ensure continuity of patient care.
- Process discharges to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnoses.
- Educates medical and coding staff on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
- Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart; reviews clinical issues with coding staff.
- Tracks response to queries; serves as a member of the CDI Work Group.
- Operates under general guidance and work assignments are varied and require interpretation and independent decisions on course of action.
- Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
- Graduate from an accredited School of Nursing required. Must obtain a Bachelor of Science in Nursing degree within 5 years of employment date.
- Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
- 1-3 years of relevant experience, required.
- CDIS or CCDS current certifications strongly preferred.