Summary: Reviews acute records of in-house patients to facilitate timely and accurate documentation and to ensure appropriate reimbursement. Provides education to physicians to assist in bridging the gap between clinical language and the requirements of documentation language for accurate, complete and compliant coding, which facilitates appropriate and accurate reimbursement. Collaborates directly with case managers, physicians, and other clinicians to ensure timely and accurate documentation. This Specialist serves as a key role to ensure a successful PHIIP (Patient Health Information Improvement Program).
1. Performs daily review of inpatient records for documentation opportunities for clarification and specificity of diagnoses and places queries on charts as necessary.
2. Assigns a working DRG and reviews documentation to identify opportunities for increased clarification and specificity of diagnoses and procedures.
3. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
4. Analyzes and trends statistical data for specified patient populations to identify opportunities for improvement.
5. Prepares educational presentations for coders, medical staff, case managers, and other departments as needed for continual documentation needs.
6. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective reviews and aggregate data analysis.
7. Works with physicians and other care givers concurrently on the units to obtain missing documentation or clarify conflicting and ambiguous documentation.
8. Monitors and evaluates the effectiveness of concurrent review outcomes as a part of the hospital's PHIIP program, trending and reporting to relevant committees throughout the year as required.
9. Efficiently demonstrate self-directed learning and participate in continuing education to meet own professional development needs and to maintain all required credentials for position.