Obtains and promotes appropriate clinical documentation.
Interacts with physicians, clinical staff and health information management professionals. Electronically to ensure proper documentation of DRGs ( Disease related Groups ).
Reviews medical records and identifies potential gaps in clinical documentation for specified patient types and payer population.
Completes concurrent review of assigned population if any.
Works in harmony with coding and CDI staff to assure documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
Submit queries to medical staff and follow-up on queries to ensure improvement documentation.
Maintains current competencies as well as updated knowledge in specific area of practice
Retrospective Consultation Services to perform retrospective review before billing process to ensure accurate hospital billing and reimbursement.