Job Summary: Responsible for the coordination of data and clinical documentation compliance to improve clinical documentation integrity. Collaborates directly with Physicians, Advanced Practice providers and HIM Coders where documentation improvement opportunities exist. Reviews clinical documentation in the medical record, through concurrent, prospective and retrospective evaluation, and queries the medical staff and other care givers as necessary to obtain accurate and complete documentation which appropriately supports the severity of patient illness, resource consumption and risk of mortality and readmissions. Ensures the accuracy and integrity of clinical documentation used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis as needed. Participates in ongoing committees as needed.
EOE AA M/F/Vet/Disability
CaroMont Health is a nationally recognized leader and trusted partner in creating a healthy community. We’ve earned that trust by combining innovative medical breakthroughs with a level of care so extraordinary it has come to define us.
Our independent healthcare system includes specialists, primary care offices, urgent care locations, emergency departments and an acute-care hospital conveniently located throughout the region. From our top doctors to our advanced technology, CaroMont Health has been recognized with numerous awards, including being named one of Thomson Reuters’ Top 100 Hospitals.