Clinical Documentation Specialist Job at Weiss Memorial Hospital
GENERAL SUMMARY:
Reporting to the Director of HIM, CDI and Coding, is responsible for improving the overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and document findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians and mid-level providers, case management, nursing staff, other patient care givers and coding staff.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
1. Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation is suspected.
2. Communicates with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient record.
3. Partners with operational and medical leadership in a given service line to identify, develop and implement successful communication and education, to engage physicians and improve processes and outcomes.
4. Rounds daily with physician and mid-level providers to ensure appropriate and accurate documentation in the medical record.
5. Ensures the level of services and acuity of care will accurately be reflected in quality outcomes.
6. Performs data collection activities to identify documentation issues, quality issues and opportunities for improvement in patient care and services.
7. Analyzes quality and patient safety data to identify patterns in the management of patient care and services using reported 1.) Hospital acquired conditions, 2.) Patient safety indicators, 3.) Case Mix Index, and 4.) Expected mortality.
Please Note :
www.bankofmontserrat.ms is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, www.bankofmontserrat.ms provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.
Reporting to the Director of HIM, CDI and Coding, is responsible for improving the overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and document findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians and mid-level providers, case management, nursing staff, other patient care givers and coding staff.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
1. Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation is suspected.
2. Communicates with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient record.
3. Partners with operational and medical leadership in a given service line to identify, develop and implement successful communication and education, to engage physicians and improve processes and outcomes.
4. Rounds daily with physician and mid-level providers to ensure appropriate and accurate documentation in the medical record.
5. Ensures the level of services and acuity of care will accurately be reflected in quality outcomes.
6. Performs data collection activities to identify documentation issues, quality issues and opportunities for improvement in patient care and services.
7. Analyzes quality and patient safety data to identify patterns in the management of patient care and services using reported 1.) Hospital acquired conditions, 2.) Patient safety indicators, 3.) Case Mix Index, and 4.) Expected mortality.
Please Note :
www.bankofmontserrat.ms is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, www.bankofmontserrat.ms provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.