Summary: Under the guidance of the Clinical Documentation Improvement Program (CDIP) Manager, this role involves conducting pre-bill and retrospective chart audits to ensure the accuracy and quality of clinical documentation supporting proper coding and Diagnosis-Related Group (DRG) assignment. The position focuses on analyzing, reviewing, and resolving coding and documentation issues related to reimbursement, compliance, and revenue enhancement.

Key Responsibilities:

• Identify trends in inaccurate coding, incomplete reviews, missed query opportunities, and high-risk areas.
• Perform second-level reviews on charts with lengths of stay exceeding expected Generalized Mean Length of Stay (GMLOS) and discrepancies in final DRG assignments.
• Conduct quality reviews on all Clinical Documentation Improvement Specialists (CDIS) charts prior to patient discharge.
• Provide constructive feedback and education to CDIS team members under the supervision of the CDIP Manager.
• Generate quality reports tailored for individual team members.
• Perform clinical pertinence chart reviews and participate in special projects as assigned.

Education and Experience:

• Five years of clinical experience in a hospital setting, or four years of recent clinical experience including at least four years in clinical documentation integrity.
• Strong knowledge of ICD-10 Coding Guidelines, MS-DRGs, APR-DRGs, and Population Management through Risk Adjustment Factors related to Hierarchical Condition Categories.
• Experience with coding and auditing inpatient medical records.

Requirements and Skills:

• Excellent observation, analytical thinking, and problem-solving abilities.
• Effective verbal and written communication skills.
• Comprehensive understanding of anatomy, physiology, disease processes, pharmacology, and medical terminology.
• Familiarity with coding education as it relates to Clinical Documentation Integrity, Risk of Mortality, and Severity of Illness measures.
• Basic computer skills including database management and presentation software.
• Ability to handle sensitive information with confidentiality and professionalism.
• Capable of working calmly under stressful conditions and meeting deadlines.
• Physical requirements include occasional light lifting, walking, and near visual acuity for proofreading.
• May involve minimal risk exposure to infectious materials.
• Willingness to travel between facilities as needed.

Licenses and Certifications:

• Registered Nurse (RN) - Board of Nursing required.

This opportunity is based in a regional healthcare setting serving the Southeastern United States, offering a collaborative environment dedicated to improving patient care through integrity and excellence.