SUMMARY:

Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses.Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient.Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

ESSENTIAL FUNCTIONS:

·Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care. Documents findings in workflow tools, noting all key information used in the tracking proce...