- Meets expectations ofthe applicable OneCHRISTUS Competencies: Leader of Self, Leader ofOthers, or Leader of Leaders.
- Maintainsconsistency with Administrative and Departmental policies withappropriate behavior, dress, attitude, attendance, confidentiality,professionalism, and reliability.
- Concurrentlyreviews selected admissions to identify the most appropriateprincipal and secondary diagnosis to accurately reflect thepatient's severity of illness.
- Communicateswith physicians and clinicians regarding missing, unclear, orconflicting medical record documentation to clarify and obtainneeded documentation.
- Develops clinician orphysician education strategies to promote complete and accuratedocumentation and correct negative trends.
- Confers with Coders concurrently to ensure appropriate DRG andcompleteness of supporting documentation.
- Develops tools and coordinates and performs audits forcompliance.
- Gathers and analyzes informationpertinent to documentation findings andoutcomes.
- Identifies patterns and trendsvariance, identifying opportunities forimprovement.
- Research literature to identifynew methods in development for disease components anddocumentation.
- Supports and is involved withongoing continuing education for both associates andphysicians.
- Performs audits as directed timelyand efficiently.
- Works with Director toenhance relationships and work closely with other departments andassociates.
- Strategizes and helps implementworkflow processes that will impact department metrics to alsoinclude regional initiatives.
- Worksindependently with little to no supervision.
- Will identify areas of improvement and provide suggestions forresolutions.
- Other duties asassigned.
- One of the followingrequired
- Foreign or domestic Medical SchoolGraduate (license not required)
- Graduate from aPhysician's Assistant program
- Graduate from aRegistered Nurse program
- 5+ years of experiencein the area of population to be served isrequired
- M. D. or D. O.; ECFMG certification(preferred for Foreign MedicalGraduates)
- Current PA or RN license required,as appropriate.
- Certified ClinicalDocumentation Specialist (CCDS) required
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Clinical Documentation Medical Professional Lead - San Antonio, United States - Christus Health
Description
Summary:
The Clinical Documentation Medical Professional (CDMP)Lead is responsible for facilitating improvement in the overallquality and completeness of the medical record documentation. TheCDMP Lead will provide support and expertise through comprehensiveassessment and review of inpatient medical records. The CDMP Leadwill facilitate accurate DRG assignment and obtain appropriatedocumentation through extensive interaction with physicians,patient caregivers, and health information management coding staffto ensure that reimbursement (reflecting the proper quality of careand appropriate reimbursement) is received for the level ofservices rendered to the patients. Offers guidance and support toRN Clinical Documentation Specialists and assists the Director asneeded.
Requirements:
Work Type:
Full Time
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