Assumes responsibility and facilitates all clinical documentation improvement initiatives for the Heart & Vascular Institute. Analyzes, educates and supports providers regarding clinical documentation integrity, to produce accurate, and complex risk capturing of our patient population.
– Responsible for the day to day evaluation of inpatient documentation for Cardiac Surgery/ Cardiology patients
– Reviews inpatient documentation for clarity of conditions/diagnosis and procedures where inadequate or conflicting documentation exists.
– Drives quality & reimbursement initiatives for the Heart & Vascular Institute, with an emphasis on maximizing clinical documentation and risk factors, especially to support Society of Thoracic Surgery (STS) Quality metrics
– Communicates with clinical staff and initiates queries based on evaluation of clinical information when documentation needs further specificity.
– Partners with the Coding Technicians to ensure accuracy of coded diagnostic and procedural data and completeness of supporting documentation to determine a working and final IR-DRG based on severity of illness and/or risk of mortality
– Conducts follow-up concurrent reviews of admissions that have incomplete or missing documentation and coordinates with the appropriate clinical or medical staff to ensure the documentation is completed prior to the patient’s discharge
– Leads Quality Improvement Projects through planning, development, implementation, and monitoring
– Collaborates with Institute, and physician, to manage a portfolio that supports the Heart & Vascular Institute priorities with impact on outcomes, reputation, and reimbursement
– Compiles data, performance analysis and advises and advises the Heart and Vascular Clinical Operations team on interpretation and/or validation of data; recommends solutions to meet objectives
– Provides education, training, and support to Providers on clinical documentation, coding guidelines, and workflow
– Develops and manages effective relationships with all stakeholders including high-level physician constituency and institute leadership team. Develop and deliver presentations regarding quality improvement projects, data and workflow analysis, issues and recommendations
– Perform other duties as assigned
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