Clinical Documentation Medical Professional - Clinical Documentation Integrity
Company: Christus Health
Location: Longview
Posted on: May 3, 2024
Job Description:
Description
Summary:
The Clinical Documentation Medical Professional is responsible for
facilitating improvement in the overall quality and completeness of
the medical record documentation. The CDMP will provide support and
expertise through comprehensive assessment and review of inpatient
medical records. The CDMP will facilitate accurate DRG assignment
and obtain appropriate documentation through extensive interaction
with physicians, patient caregivers and health information
management coding staff to ensure that reimbursement (reflecting
proper quality of care and appropriate reimbursement) is received
for the level of services rendered to the patients.
- Performs concurrent and retrospective reviews of the medical
record utilizing practice experience, 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 ensures appropriate reimbursement is received for the level of
service rendered to all patients.
- Utilizes research, analytic data, observations, and practice
experience 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.
- Analyzes clinical information. Formulates appropriate clinical
documentation clarifications to improve documentation. Queries and
educates physicians and key healthcare providers regarding clinical
documentation improvement.
- In conjunction with CDI leadership, tracks response to clinical
documentation and trends in CDI metrics.
- Maintains and enhances current medical, coding and CDI
knowledge by participating in continuing education offerings,
CMEs.
- Consistently meets established productivity targets for record
review.
- Assists in collection and organization of data for analysis by
appropriate medical and hospital committees.
- Takes personal responsibility to ensure compliance with all
policies, procedures and standards as promulgated by state and
federal agencies, the hospital, and other regulatory entities.
- Performs all duties in a manner that protects the
confidentiality of the patient and does not solicit or disclose any
confidential information unless it is necessary in the performance
of assigned job duties.
- Performs other duties as assigned.
Requirements:
- Foreign or domestic Medical School Graduate (license not
required), OR
- Graduate from a Physician's Assistant or RN Program.
- Graduate from a Registered Nurse Practitioner program
preferred.
- A minimum of 3 years of experience in area of population to be
served is required
- Three (3) years pervious acute hospital inpatient coding
experience highly preferred
- M. D. or D. O.; ECFMG certification (preferred for Foreign
Medical Graduates)
- RN or Current PA or RNP license required, as appropriate
- Certified Clinical Documentation Specialist (CCDS) highly
preferred
Work Type:
Full Time
Keywords: Christus Health, Longview , Clinical Documentation Medical Professional - Clinical Documentation Integrity, Healthcare , Longview, Texas
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