The duties listed below are a summary of the major essential functions of this position. The position may require other duties, both major and minor, that are not mentioned, and specific functions may change from time to time.
- Facilitates appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided to acute care patients are accurately reflected in the medical record. Ensures an appropriate DRG is assigned to each patient with a DRG based payer, and an appropriate reimbursement is received for the level of services rendered. Ensures the working DRG is entered in the hospital computer system. Accurately enters required information in the medical record and computer system.
- Reviews clinical issues and performs clinical validation reviews with HIM coding staff to assign an accurate working DRG.
- As appropriate, participates in Performance Improvement data collection, evaluation and recommendations for improvement. Refers quality issues to the Department Director.
- Ensures the accuracy and completeness of clinical information is used for measuring and reporting physician and hospital outcomes.
- Updates the DRG Worksheet to reflect changes in status, procedures/treatments, and confers with physician to finalize diagnoses. Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with physician have been recorded in the patient’s chart.
- Educates internal customers on clinical documentation opportunities, clinical validation of assigned diagnoses, coding and reimbursement issues, as well as performance improvement methodologies.
- Serves as a member of the CDI Task Force and Clinical Documentation Team, assists with special projects as needed and performs related duties as assigned. Tracks response to CDI and trends completion of DRG worksheets.
- Communicates effectively with patient care team to clarify issues and collaboratively obtain complete and accurate documentation in the medical record.