Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program® (CDMP®) documentation strategies Accurate and timely record review Recognize opportunities for documentation improvement Initiates CDMP® severity worksheet for inpatients Formulate clinically credible documentation clarifications
Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety Effective and appropriate communication with physicians Timely follow up on all cases and resolution of those with clinical documentation clarifications Participate in Task Force Meetings Manage multiple priorities Communicates with HIM staff and resolves discrepancies Accurate input of data into CDMP Trak®
Ability to learn/develop the skills necessary to perform CDMP® Organizational, analytical, writing and interpersonal skills Dependable, self-directed and pleasant Critical thinking, problem solving and deductive reasoning skills Knowledge of Pathophysiology and Disease Process Basic Computer skills, familiarity with Windows based software programs Knowledge of regulatory environment Understand and support CDMP® documentation strategies (upon completion of training) Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training) Knowledge of Core Measure and Patient Safety Indicators (upon completion of training) . 5 years of adult acute care experience in Med/Surg, Critical Care, Case Management, Emergency Room, or PACU.
Graduation from a program of nursing, BSN, preferred. Current State Registered Nurse License.