Clinical Documentation Medical Professional Lead - Clinical Documentation Integrity

Summary:

The Clinical Documentation Medical Professional is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDMP will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDMP will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement (reflecting proper quality of care and appropriate reimbursement) is received for the level of services rendered to the patients.

• Performs concurrent and retrospective reviews of the medical record utilizing practice experience, evidence-based knowledge, protocols, and criteria.
• Works closely with the medical staff and other healthcare team member to help identify potential gaps in physician documentation and ensures appropriate reimbursement is received for the level of service rendered to all patients.
• Utilizes research, analytic data, observations, and practice experience to provide recommendations to improve the overall quality and completeness of clinical documentation.
• Establishes cooperative and multidisciplinary relationships with physicians, coding staff and other health team members.
• Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs, and successful problem resolution.
• Demonstrates familiarity with MS-DRG/APR-DRG’s and Inpatient Prospective Payment System (IPPS).
• Completes initial reviews of patient records to evaluate documentation to identify and assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate assignment of the working DRG, risk of mortality, and severity of illness.
• Completes follow-up reviews.
• Reviews a minimum of standard charts per day as directed.
• Analyzes clinical information. Formulates appropriate clinical documentation clarifications to improve documentation. Queries and educates physicians and key healthcare providers regarding clinical documentation improvement.
• In conjunction with CDI leadership, tracks response to clinical documentation and trends in CDI metrics.
• Maintains and enhances current medical, coding and CDI knowledge by participating in continuing education offerings, CMEs.
• Consistently meets established productivity targets for record review.
• Assists in collection and organization of data for analysis by appropriate medical and hospital committees.
• Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities.
• Performs all duties in a manner that protects the confidentiality of the patient and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.
• Performs other duties as assigned.

CHRISTUS Santa Rosa Hospital - Westover Hills (CSRH-WH) is a 150-bed hospital serving the fastest growing area of San Antonio. Specialized care includes orthopedic and surgical services, ICU, women’s services, a newborn nursery, comprehensive cardiovascular care from diagnostics to open heart surgery, vascular lab, sleep center, emergency services, the CHRISTUS Weight Loss Institute, wound care, rehabilitation, and more. The campus also boasts an Outpatient Imaging Center and three medical plazas, one of which houses our CHRISTUS Santa Rosa Family Medicine Residency Program and CHRISTUS Santa Rosa Family Health Center.

Requirements:

A. Education/Skills

• Foreign or domestic Medical School Graduate (license not required), OR
• Graduate from a Physician’s Assistant or RN Program.
• Graduate from a Registered Nurse Practitioner program preferred.

B. Experience

• A minimum of 3 years of experience in area of population to be served is required
• Three (3) years pervious acute hospital inpatient coding experience highly preferred

C. Licenses, Registrations, or Certifications

• M.D. or D.O.; ECFMG certification (preferred for Foreign Medical Graduates)
• RN or Current PA or RNP license required, as appropriate
• Certified Clinical Documentation Specialist (CCDS) highly preferred

Work Type:

Full Time

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