Job Summary
Improves the overall quality and completeness of clinical documentation through the application of evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation. Interacts primarily with, but not limited to, physicians, nursing staff, other patient caregivers and health information coding staff to capture appropriate reimbursement and clinical severity for the level of service rendered to all patients, with a focus on DRG-based payers. Facilitates timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes in compliance with regulatory standards. Educates all members of the patient care team on issues relating to clinical documentation. Works with Clinical Data Analyst - ICCM to quantify complete and accurate clinical documentation and utilization, focusing on DRG payers.
Demonstrates knowledge of DRG payer issues for documentation opportunities, clinical documentation requirements, coding standards as applied to medical record documentation and compliance requirements. Demonstrates working knowledge of APR DRG's and intensity of service criteria.

Applies teaching/learning principles in establishing an overall educational program related to effective clinical documentation for, and in collaboration with, physicians and the health care team.

Develops and maintains close working relationships with physicians and the departments of coding, nursing, health information management, quality and managed care, as well as ancillary departments responsible for clinical documentation.
Position requires self-directed, independent decision-making, analytical teaching and articulate communication skills, both verbal and written. Assumes responsibility and accountability for incorporating the mission, vision, values and critical goals of the organization into job performance.

Demonstrates enhanced knowledge of anatomy and pathophysiology to facilitate the increased need for granularity and specificity in the clinical documentation with the transition to new coding systems. Demonstrates the ability to accurately utilize coding guidelines, software and resource material. Provides informal and formal education on required documentation and acts as a resource to physicians and other members of the health care team.

• Performs concurrent and retrospective (as required) medical record review utilizing evidence-based knowledge, protocols, and criteria. Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients and DRG payors. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and Hospital outcomes. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
  
• Communicates and interacts with physicians and clinical staff, verbally and through the use of written communication tools, observations and recommendations to improve the overall quality and completeness of clinical documentation.
  
• Establishes cooperative and multidisciplinary relationships with physicians and health team members including successful problem resolution and acts as a resource to the health team members related to optimal documentation.
  
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. Tracks response to clinical documentation and trends completion of the process, e.g. DRG worksheets.
  
• Develops and implements formal and informal educational programs related to documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians.
  
• Designs, generates and evaluates the effectiveness of reports and evaluation tools, in conjunction with the Clinical Analyst- ICCM, utilizing multiple data systems in order to analyze impact of the documentation improvement process.
  
• Analyzes and compiles accurate and complete data for statistical reporting and educational presentations.
  
• Analyzes, summarizes and documents outcomes of documentation improvement process for re-evaluation of ongoing program revisions. Participates as a member of work groups related to clinical documentation, utilization and compliance, if required.
  
• Conducts, in collaboration with case management, medical record reviews evaluating the utilization of facilities and services for appropriate levels of patient care. Performs admission/continued stay reviews using clinical documentation guidelines and Interqual criteria, focusing on DRG payor.
  
• Assumes responsibility and accountability for incorporating the vision, values, mission and critical goals of the organization into job performance.