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CLINICAL DOCUMENT SPECIALIST - RHIA / RHIT (Hybrid)
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Full-time
- Responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment for billing integrity.
- Collaborates with HIM Coders to ensure that the clinical information used in measuring and reporting outcomes is complete and accurate and reimbursement is received fro the level of services rendered to patients with DRG-based payers.
- Completes admission reviews of patient records within 24-48 hours of admission for specified patient population to evaluate documentation and generate the working DRG. Conducts concurrent follow-up reviews of records as necessary, not to exceed 4 days from prior review.
- Update notes and revise working DRG based on new documentation.
- Document all reviews in the CDI application to facilitate tracking, data collection, and communication with coders and department leaders.
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