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Clinical Documentation Special: Kingwood Medical Center

Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care deliver to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.
· Provides concurrent review of the clinical documentation in the medical record.
· Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
· Performs a thorough chart review to identify that co-morbidities/complications are documented appropriately.
· Completes the DRG worksheet and reviews documentation of the medical record every 2-3 days.
· Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.
· Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.
· Maintains the ability to be flexible, and prioritizes daily responsibilities.