Clinical Doc Improvement Spec I

Clinical Doc Improvement Specialist 1 performs patient record reviews concurrently and/or retrospectively to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Creates queries to physicians when needed to clarify ambiguous or incomplete documentation. The Clinical Doc Improv Spec 1 should have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality. WORK MODEL: 100% Remote

Facilitates accurate and complete documentation of medical conditions and treatment in patient records. Performs review of record to determine complete, accurate documentation of patient condition and treatment. As appropriate, the working DRG is updated. Promotes and obtains appropriate documentation for any clinical conditions or procedures to support the appropriate severity of illness (SOI), expected risk of mortality (ROM) and complexity of care of the patient through extensive interaction with practitioners. Proficiently query practitioners regarding missing, unclear, or conflicting health record documentation in an effort to obtain additional documentation within the health record as needed. Appropriately escalates provider non-responses or inappropriate responses for reconciliation. Collaborates with Health Information Management coders and or auditors to reconcile working versus final coded DRG. Collaborates with peers who work directly with physicians.