Compliance Documentation Improvement Specialist

About the role

Clinical Documentation Improvement position within Enterprise Corporate, responsible for reviewing inpatient medical records to ensure accurate documentation, coding, and compliance.

Responsibilities

• Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses.
• Appropriately assigns the MS‑DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
• Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP‑DRG) and Medical Severity Diagnostic Related Group System (MS‑DRG).
• Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
• Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
• Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
• Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
• Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
• Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.

Requirements

• Registered Nurse applicable state licensure required.
• Bachelor's Degree required.
• Appropriate professional certification required within 3 years of hire date per department protocol.