Clinical Documentation Improvement Specialist/ Query Writer
- Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining documentation within the health record. Promotes appropriate clinical documentation to accurately reflect the patient's severity of illness, working diagnosis, and clinical course of hospitalization.
- Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures.
- Follows guidelines for coding and documentation to ensure physicians and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation.
- Responsible for improving the overall quality and completeness of clinical documentation. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes
- Improve documentation of all conditions and treatments in the discharged medical record to ensure an accurate reflection of the patient condition in the associated DRG, case mix index, severity of illness, risk of mortality, profiling and reimburesemnt.
- Analyzed aggregated data to identify patterns and areas of focus for documentation and coding improvement initiatives/education.
- Implement strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
- Plans, performs or supervises audits. Develops an audit corrective action plan for improvement and monitors compliance with the plan.
- Assists with coding and CDI questions, provides guidance memos on coding and clinical documentation related issues/topics.
- Develops and educates the coding and CDI staff, as well as physicians if necessary, in understanding the coding and clinical documentation requirements for diagnosis capture, in al with regulatory standards and coding guidelines.
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