Compliance

• Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered.
• Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process.
• Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant.
• Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.
• Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses.
• Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
• Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
• Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
• Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
• Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
• Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
• Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
• Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.

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