Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Will play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services: Prepares and conducts educational programs for interns, residents and medical staff regarding appropriate clinical documentation and coding requirements. Coordinates communications between coding and the medical staff in support of quality documentation and accuracy in the coding and reimbursement/revenue cycle process.
Skills & Abilities:
Knowledge of care delivery documentation systems and related medical record documents. Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clnical knowledge and understanding of pathology/physiology of disease processes. Excellent written and verbal communication skills. Working knowledge of inpatient admission criteria. Ability to work independently in a time-oriented environment. Computer literacy and familiarity with the operation of basic office equipment. Assertive personality traits to facilitate ongoing physician communication. Working knowledge of Medicare reimbursement system and coding structures.
Training & Education:
Nursing degree: RN
Minimum of three years of clinical experience in an acute care setting.
Required Licenses: RN