About this role
Role Overview
- Provide timely reviews of patient medical records to ensure accurate and complete documentation
- Work with providers and coders to ensure documentation reflects complexity of the patient
- Educate and interact with providers
- Ensure inpatient clinical documentation accurately reflects severity of illness (SOI) and Risk of Mortality (ROM)
- Ensure Present on Admission (POA) clinical conditions are documented accurately
- Participate in education sessions and feedback to coders, CDI Reviewers, and Hospital Quality Departments
- Conduct regular audits to ensure compliance with POA, HACs and PSI documentation
- Track and trend data for use in CDI and Coding team quarterly data quality reviews
- Escalate any observed issues impacting quality of documentation or coding
- Ensure compliance with CMS rules and regulations for coding and DRG assignment
- Familiar with OIG workplan to determine payor denial patterns
Requirements
- RN required
- Iodine experience required
- 2+ years of clinical documentation experience
- Strong clinical training experience
- APR experience required
- 3+ years of acute care experience required
- Strong analytical skills to clinically evaluate medical record
- Ability to use a PC for medical record review along with proficiency utilizing Microsoft products (Excel, Word, Outlook)
- Ability to communicate effectively with e4health management and clients
- BSN Preferred
- Smarter Dx experience
- Epic & 3M 360
Benefits
- excellent salary
- full benefits package including 401(k) with company match
- medical
- dental
- vision
- life insurance
- short/long term disability insurance
- PTO policy