Inpatient Clinical Documentation Integrity
3 weeks ago
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Key Responsibilities
Clinical Documentation and Coding Accuracy:
· Conduct comprehensive reviews of inpatient medical records to validate clinical documentation and ensure ICD-10-CM/PCS coding accuracy.
· Collaborate with providers to ensure documentation supports accurate DRG assignments, SOI, ROM, as well as CCs and MCCs.
· Address documentation gaps, inconsistencies, and areas requiring clarification through focused queries.
· Analyze coding data to identify discrepancies, trends, and areas for improvement.
· Ensure diagnoses critical for mortality and other risk models are documented as "POA."
Subject Matter Expertise:
· Serve as a key resource for inpatient coding, DRG assignments, and SOI assessments.
· Work closely with coding teams to resolve discrepancies and enhance coding accuracy.
Collaboration and Education:
· Build strong partnerships with physicians, CDI specialists, and clinical teams to bridge documentation gaps.
· Provide targeted education and training on documentation standards, compliance, and best practices.
· Facilitate training sessions to enhance understanding of CDI processes and their impact on quality metrics and reimbursement.
· Function as a liaison between clinical teams, coders, and revenue cycle management.
Compliance and Auditing:
· Ensure all documentation adheres to regulatory standards, including CMS, Joint Commission, and other compliance requirements.
· Participate in audits, evaluate findings, and recommend corrective actions, as needed.
· Support organizational quality initiatives and contribute to performance improvement projects.
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Qualifications and Skills
Required Credentials and Experience:
· Certifications: CDIP, CCDS, or CCS.
· Experience: At least 7 years in US healthcare with a focus on inpatient coding, CDI processes, or data quality audits, demonstrating strong expertise in ICD-10-CM/PCS coding and DRG assignments.
· Advanced knowledge of US healthcare reimbursement methodologies, including MS-DRG and APR-DRG.
· Familiarity with payer-specific policies, official coding guidelines, and regulatory standards (e.g., CMS, AHIMA).
· Proficiency in EHR systems (e.g., Epic, Oracle-Cerner) and coding tools (e.g., 3M, Nuance, Optum).
Desired Skills:
· Exceptional analytical skills to identify trends and resolve discrepancies in documentation and coding.
· Outstanding interpersonal and communication abilities to foster collaboration and provide education.
· Proven track record of delivering effective training sessions and analyzing CDI metrics such as query response rates and documentation improvements.
· Up-to-date knowledge of regulatory changes and industry best practices in CDI.
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