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Duties &
Responsibilities:
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Job Summary
Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, and nursing. Also responsible for utilization review and resource management of the case based on clinical documentation found in the patient record.
Duties
- Completes initial reviews of patient records to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnosis, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet.
- Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary.
- Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
- Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
- Collaborates with discharge planners, nursing staff, and other ancillary staff regarding interaction with physicians on documentation to resolve physician queries prior to patient discharge.
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews.
- Facilitates change processes required to capture needed documentation by communicating with department leadership.
- Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
- promote improved quality of care
- promote cost effective medical outcomes
- promote decreased length of hospital stays when appropriate
- assure appropriate levels of care are received by patients
- Performs other duties as assigned
Organizational Expectations
- Provides a positive and professional representation of the organization
- Promotes culture of safety for patients and employees through proper identification, reporting, documentation, and prevention
- Maintains hospital standards for a clean and quiet patient environment to maintain a positive patient care experience
- Adheres to infection-control policies and protocols
- Participates in ongoing quality improvement activities
- Maintains compliance with organization’s policies, as well as established practices, protocols, and procedures of the position, department, and applicable professional standards
- Complies with organizational and regulatory policies for handling confidential patient information
- Demonstrates excellent customer service through his/her attitude and actions, consistent with the standards contained in the Vision, Mission, and Values of the organization
- Adheres to professional standards, hospital policies and procedures, federal, state, and local requirements
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