Clinical Documentation Medical Professional

2 weeks ago

San Antonio, Texas, United States Christus Health Full time

Summary:

The Clinical Documentation Medical Professional isresponsible for facilitating improvement in the overall quality andcompleteness of the medical record documentation. The CDMP willprovide support and expertise through comprehensive assessment andreview of inpatient medical records. The CDMP will facilitateaccurate DRG assignment and obtain appropriate documentationthrough extensive interaction with physicians, patient caregiversand health information management coding staff to ensure thatreimbursement (reflecting proper quality of care and appropriatereimbursement) is received for the level of services rendered tothe patients.

Responsibilities:

  • Performs concurrent and retrospective reviewsof the medical record utilizing practice experience, evidence-basedknowledge, protocols, and criteria.
  • Worksclosely with the medical staff and other healthcare team member tohelp identify potential gaps in physician documentation and ensuresappropriate reimbursement is received for the level of servicerendered to all patients.
  • Utilizes research,analytic data, observations, and practice experience to providerecommendations to improve the overall quality and completeness ofclinical documentation.
  • Establishescooperative and multidisciplinary relationships with physicians,coding staff and other health team members.
  • Acts as a resource to the CDI department andhealth team members related to optimal documentation, educationalneeds, and successful problem resolution.
  • Demonstrates familiarity with MS-DRG/APR-DRG's and InpatientProspective Payment System (IPPS).
  • Completesinitial reviews of patient records to evaluate documentation toidentify and assign the principal diagnosis, pertinent secondarydiagnoses, and procedures for accurate assignment of the workingDRG, risk of mortality, and severity ofillness.
  • Completes follow-upreviews.
  • Reviews a minimum of standard chartsper day as directed.
  • Analyzes clinicalinformation. Formulates appropriate clinical documentationclarifications to improve documentation. Queries and educatesphysicians and key healthcare providers regarding clinicaldocumentation improvement.
  • In conjunction withCDI leadership, tracks response to clinical documentation andtrends in CDI metrics.
  • Maintains and enhancescurrent medical, coding and CDI knowledge by participating incontinuing education offerings, CMEs.
  • Consistently meets established productivity targets for recordreview.
  • Assists in collection and organizationof data for analysis by appropriate medical and hospitalcommittees.
  • Takes personal responsibility toensure compliance with all policies, procedures and standards aspromulgated by state and federal agencies, the hospital, and otherregulatory entities.
  • Performs all duties in amanner that protects the confidentiality of the patient and doesnot solicit or disclose any confidential information unless it isnecessary in the performance of assigned job duties. Performs otherduties as assigned.

Requirements:

  • Foreign or domestic Medical School Graduate(license not required), OR
  • Graduate from aPhysician's Assistant or RN Program.
  • Graduatefrom a Registered Nurse Practitioner programpreferred.
  • A minimum of 3 years of experiencein area of population to be served is required
  • Three (3) years pervious acute hospitalinpatient coding experience highly preferred
  • M.D. or D. O.; ECFMG certification (preferred for Foreign MedicalGraduates)
  • RN or Current PA or RNP licenserequired, as appropriate
  • Certified ClinicalDocumentation Specialist (CCDS) highlypreferred

WorkType:

Full Time

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