01Overview
Responsibilities
Demonstrate clinical expertise with a minimum of 7+ years of inpatient experience.
Communicate with providersverbally or in writing (e.g., formal queries)to clarify missing, unclear, or conflicting health record documentation, ensuring timely follow-up.
Understand and explain the impact of complications, comorbidities, SOI, risk of mortality (ROM), case mix, and procedures on billing and documentation.
Collect and analyze documentation findings and outcomes to develop action plans for process improvement. Prepare internal monitoring reports and compile data for reporting.
Collaborate with physicians and clinic leadership to develop and monitor key performance indicators for clinical documentation. Provide report explanations to clinical staff as needed.
Facilitate communication among coders and providers to identify documentation opportunities that accurately reflect patient acuity and risk.
Skills & Competencies
Ability to work independently, self-motivate, and adapt to the evolving healthcare landscape.
Strong verbal and written communication skills, analytical thinking, and problem-solving abilities with keen attention to detail.
Solid understanding of medical terminology and procedures for evaluating clinical documentation.
Excellent organizational and planning skills, with the ability to manage multiple priorities in a dynamic environment.
Proficiency in using computers, including databases, spreadsheets, presentation tools, word processing, and internet research.
Knowledge of federal, state, and private payer regulations, along with relevant organizational policies and procedures.
Commitment to staying informed about changes in healthcare reform and coding regulations, and integrating these updates into chart reviews and educational efforts. .
