Clinical Documentation Improvement Coordintor

Clinical Documentation Improvement Coordinator Summary :

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.

Essential Responsibilities and Duties :

Provides advanced level review of inpatient medical records to identify gaps in clinical documentation.

Ensures consistency of data captured by strictly following existing guidelines and constantly providing timely feedback to healthcare providers.

Follows-up with the healthcare providers regarding existing clarifications to obtain needed documentation specification.

Engages healthcare providers in ongoing educational sessions in regards to documentation improvement.

Reports any gaps, lack of compliance, and findings in the medical records to the responsible Manager or Team Leader.

Engages medical staff in the process of reviewing clinical documentations for better awareness and smooth knowledge transfer.

Maintains a record of clinical documentation reviews performed and the gaps identified.

Performs other related duties as assigned.

Job Requirements

Education : Bachelor’s or Associate Degree / Diploma in Nursing, Health Information Management or other healthcare related discipline is required.

Experience Required : Four (4) years of related experience with Bachelor’s, or six (6) years with Associate Degree / Diploma is required.

Seniority level

Associate

Employment type

Full-time

Job function

Health Care Provider

Industries

Hospitals and Health Care

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