Responsible for reviewing medical records for completeness by monitoring the
healthcare providers' compliance about recording the patient's medical related
data (treatments, medications, requests) to support the accurate assignment of
codes.
1. Provides advanced level review of inpatient medical records to identify
gaps in clinical documentation.
2. Ensures consistency of data captured by strictly following existing
guidelines and constantly providing timely feedback to healthcare providers.
3. Follows-up with the healthcare providers regarding existing clarifications
to obtain needed documentation specification.
4. Engages healthcare providers in ongoing educational sessions in regards to
documentation improvement.
5. Reports any gaps, lack of compliance, and findings in the medical records
to the responsible Manager or Team Leader.
6. Engages medical staff in the process of reviewing clinical documentations
for better awareness and smooth knowledge transfer.
7. Maintains a record of clinical documentation reviews performed and the
gaps identified.
8. Maintains positive relationship and communication with the lead coder and
other related departments.
9. Participates in self and others education, training and development as
applicable.
10. Follows all Hospital 's policies and procedures.
11. Performs other related duties as assigned.
Bachelor 's or Associate Degree/Diploma in Nursing, Health Information
Management or other healthcare related discipline is required.
Four (4) years of related experience with Bachelor 's, or six (6) years with
Associate Degree/Diploma is required.
? Certified Clinical Documentation Improvement or Health Information
Management is preferred.
? Experience as an RHIA, CCC, CHIM and/or verifiable documentation review
experience gained in a tertiary care setting is preferred.
? Certified Medical Coder (AR-DRG) is preferred.
? Experience with medical insurance is preferred.
? Deep knowledge of medical documentation.
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