Description
Facilitates and obtains appropriate and complete medical record documentation to reflect patient acuity level and care provided. Ensures that clinical documentation is accurately and compliantly captured at the point of service. Responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment for billing integrity. Reviews all provider documentation as necessary to ensure complete and accurate documentation. Collaborates with HIM Coders to ensure that the clinical information used in measuring and reporting outcomes is complete and accurate and reimbursement is received fro the level of services rendered to patients with DRG-based payers. Participates in education of members of the patient care team on documentation guidelines as guided by department leadership. Collect and analyze data to provide reports and make recommendations. Completes admission reviews of patient records within 24-48 hours of admission for specified patient population to evaluate documentation and generate the working DRG.
