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Clinical Documentation Medical Professional

3 months ago

San Antonio, Texas, United States Christus Health Full time

Summary:
The role of the Clinical Documentation Medical Professional (CDMP) is crucial in ensuring the accuracy and completeness of medical records. By collaborating with physicians, caregivers, and coding staff, the CDMP plays a key role in securing proper reimbursement for patient services. This position involves ongoing reviews of medical records, providing recommendations for documentation improvement, and building strong relationships within the healthcare team.

  • Conducts concurrent and retrospective reviews using evidence-based knowledge.
  • Collaborates with healthcare team to address documentation gaps and ensure proper reimbursement.
  • Utilizes research and practice experience to enhance clinical documentation quality.
  • Establishes cooperative relationships with physicians and coding staff.
  • Acts as a resource for CDI department and healthcare team members.
  • Demonstrates proficiency in MS-DRG/APR-DRG's and IPPS.
  • Completes initial and follow-up reviews, maintaining productivity targets.
  • Analyzes clinical information and provides documentation clarifications.
  • Track and report on response to clinical documentation.
  • Keeps medical knowledge current through continuing education.
  • Ensures compliance with policies, procedures, and confidentiality standards.

Requirements:

  • Medical School Graduate or Graduate from a PA or RN Program.
  • Minimum 3 years of relevant experience.
  • Acute hospital inpatient coding experience preferred.
  • M.D. or D.O.; ECFMG certification; RN or Current PA/RNP license required.
  • Certified Clinical Documentation Specialist (CCDS) highly preferred.
Work Type:
Full Time