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clinical documentation improvement specialist

  • Comprehensive review of initial and concurrent inpatient documentation to ensure that severity of illness, utilization of services, and risk of mortality are documented to validate selected DRG’s, using 3M coding software.
  • Identification of opportunities for improvement in clinical documentation to validate active diagnoses and increase SOI and ROM resulting in highest potential hospital reimbursement for services.
  • Communicate with physicians to clarify information, obtain needed documentation for appropriate MS-DRG selection based on severity of illness.
  • Follow up and collaborate with physicians and appropriate health care team members to resolve documentation issues and ensure accurate and complete documentation in the medical record.
  • Adhering to the standards of ethical coding per ICD-10 CM coding guidelines.
  • Coordinates and conducts regular meeting with HIM Coding Professionals for DRGs reconciliation and discuss questions related to Coding and CDI.

clinical documentation improvement specialist

  • Quality Specialist working closely with hospital physicians to improve the quality of documentation.