Summary
Responsible for reviewing medical records for completeness by monitoring the healthcare providers’ compliance about recording the patient’s medical related data (treatments, medications, requests) to support the accurate assignment of codes.
Essential Responsibilities and Duties
1. Provides advanced level review of inpatient medical records to identify gaps in clinical documentation.
2. Ensures consistency of data captured by strictly following existing guidelines and constantly providing timely feedback to healthcare providers.
3. Follows-up with the healthcare providers regarding existing clarifications to obtain needed documentation specification.
4. Engages healthcare providers in ongoing educational sessions in regards to documentation improvement.
5. Reports any gaps, lack of compliance, and findings in the medical records to the responsible Manager or Team Leader.
6. Engages medical staff in the process of reviewing clinical documentations for better awareness and smooth knowledge transfer.
7. Maintains a record of clinical documentation reviews performed and the gaps identified.
8. Maintains positive relationship and communication with the lead coder and other related departments.
9. Participates in self and others education, training and development as applicable.
10. Follows all Hospital’s policies and procedures.
11. Performs other related duties as assigned.
Education
Bachelor’s or Associate Degree/Diploma in Nursing, Health Information Management or other healthcare related discipline is required.
Experience Required
Four (4) years of related experience with Bachelor’s, or six (6) years with Associate Degree/Diploma is required.
Other Requirements(Certificates)
? Certified Clinical Documentation Improvement or Health Information Management is preferred.
? Experience as an RHIA, CCC, CHIM and/or verifiable documentation review experience gained in a tertiary care setting is preferred.
? Certified Medical Coder (AR-DRG) is preferred.
? Experience with medical insurance is preferred.
? Deep knowledge of medical documentation
