Clinical Documentation Improvement Specialist
Current* Conducting daily, concurrent review of inpatient records on to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate, timely, and compliant coding.* Updating “working DRG” as documentation supports or physician query answer supports a change in the DRG assignment* Issuing compliant physician queries when documentation is confusing, ambiguous or missing and follows up with MD to seek immediate response to query.* Analyzing complete clinical documentation from a compliance, coding and/or reimbursement perspective including rationale for the initiation, discontinuation and/or adjustment of treatment modalities utilized in the care of the patient.* Reviewing HACs/PSIs and finding potential reversals based on exclusion criteria.
