أخصائي تكامل التوثيق السريري والترميز الطبي

The CDI primary role will be auditing inpatient/ outpatient cases for DRG validation and/or documentation improvement opportunities utilizing a unique approach that combines technology, coding and clinical documentation auditing expertise. Responsibilities include working directly with the Physicians, Coders and CDI team members to streamline processes, identify training needs and ensure consistent information is shared. Provide training, as needed to ensure quality and productivity standards are met. This person should have strong coding skills, extensive knowledge of medical terminology, the human disease process, and anatomy & physiology, along with a thorough understanding of the workflow and processes utilized by the team members to successfully complete review processes. Viewed as an expert, highly sought-after resource, and a key advisor to other business partners. Ensures compliance of coding/billing and charging with regulatory and accreditation standards.

Responsibilities

• Prepares medical records in the inpatient and/or outpatient setting to capture an accurate representation of the severity of illness and facilitate proper coding.
• Improves documentation practices to reflect quality and outcome scores.
• Develops and educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record;
• Obtains and promote appropriate clinical documentation through extensive interaction with physicians to ensure that the documentation of the level of service rendered to the patient and the patient's clinical complexity is complete and accurate;
• Performs remote and on-site paper or electronic medical chart review and clinical validation audits and interpretation of medical documentation to ensure clinical support of all relevant coding based on AHIMA guidelines;
• Facilitates and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient
• Assess review data to determine areas of improvement for follow up physician training and communication
• Utilizes query process when code assignments are not straightforward or documentation is not clear for coding purposes;
• Maintains Clinician focused process design, data analysis, and improvement strategies to drive project execution for high quality/high priority outcomes;
• Assess clinical aspects of medical record documentation to drive improvement and consistency in application across Medical Group adult primary care and specialty clinics.
• Prepares spreadsheets to collect and support chart review findings;
• Recommends necessary training to correct deficiencies for the department/section
• Communicates effectively all relevant policies and procedures, of the facility to the current and prospective employees
• Contributes to the processes used in the performance of the CDS role, through SOP development and revision, and process improvement
• Responsible for providing accurate information to the management, finance leadership, and medical team.
• Contributes to the processes used in the performance of the CDS role, through SOP development and revision, and process improvement
• Maintains patient medical records in the inpatient and/or outpatient setting to capture an accurate representation of the severity of illness and facilitate proper coding.
• Determines and validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient’s illness along with expected risk of mortality and complexity of care.

Qualifications

Experience :-
Required:
• Experience in IR-DRG, ICD10 and CPT
• Experience with Statistical analysis/ Data Analysis
• Experience with Microsoft Office Tools
• Experience in a large healthcare facility
Desired:
• Experience in a large healthcare facility
• Experience in IR-DRG and ICD10
Educational Qualification: Required:
• Any of the following: Registered Health Information Technician (RHIT), Certified Coding