Clinical Documentation Specialist
Perform concurrent reviews of medical records to ensure accurate documentation of medical necessity. These reviews include an assessment of severity of illness/risk of mortality, correct MS-DRG assignment, appropriate revenue capture, case mix index, and support for Core and Quality Measures.
- Perform follow-up reviews to ensure diagnostic clarification queries have been answered.
- Educate physicians and other healthcare professionals as needed regarding the relationships between documentation, coding, and quality.
- Perform daily geometric mean length of stay (GMLOS) assignments on all inpatient cases, based on the working DRG for each case.
- Formulate CDI queries [online and written] based on clinical indicators in compliance with organizational and federal [CMS/AHIMA] guidelines.
- Educate CDI physician advisors on best practices for accurate coding and documentation.
- Maintain CDI monitor database including response rate (99%), agreement rate (98%), tracking and trending of diagnosis clarification queries.
- Collaborate with the coding department to ensure proper documentation of discharge diagnoses and comorbidities, in order to accurately reflect patients' medical records.