1. Responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record.

2. Assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered.

3. Extensively interacts with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff.

4. Ensures that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

5. Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

6. Fosters a collaborative environment with the HIM department team.

7. Ability to critically and effectively analyze documentation in the medical record.

8. Ability to develop and maintain compliant query practices.

9. Knowledge of how clinical documentation impacts quality initiatives.

10. Other duties as assigned 

EDUCATION EXPERIENCE REQUIREMENTS:

Active RN license in good standing

Minimum 5 years CDI experience

ACDIS or AHIMA credentials preferred (CCDS, CDIP)