Assist the providers with accurately identifying and documenting the healthcare services provided to the patient.
Analyze clinical information, using the documentation as the primary driver for overall System Case Mix Index.
Evaluate the documentation in order to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness.
Formulate queries when there is missing documentation, conflicting documentation or unclear documentation.
Provide ongoing education to physicians and essential healthcare providers regarding clinical documentation improvement.
Collaborate with nursing staff, clinical nutrition, pharmacists, along with the physicians on documentation.
Maintain the confidentiality of all information acquired pertaining to the patient, physician, associates, and visitors.
Requirements
Must currently hold the required CDI certification in order to be considered for this position.