What are the responsibilities and job description for the Clinical Documentation Review Specialist position at Robert Half?
We are welcoming a Clinical Documentation Review Specialist to join our healthcare team in Rancho Cordova, California. This role involves a meticulous examination of hospital medical documentation, communication with medical staff, and ensuring appropriate reimbursement for the hospital reflecting the complexity and severity of patient care.Responsibilities:• Evaluate medical record documentation concurrently on the nursing units to guarantee clear and comprehensive documentation by physicians.• Engage with physicians concerning missing, unclear, or conflicting medical record documentation and secure additional documentation within the medical record to assist with the correct code assignment.• Offer documentation and coding education to patient care providers.• Participate in retrospective chart reviews to assess the effectiveness of physician prompting.• Contribute to the analysis and trending of statistical data for specified patient populations to identify areas for improvement.• Ensure accurate completion of worksheets for performance tracking reports.• Make decisions about the interpretation and clarification of inpatient documentation and determine when to prompt physicians for more complete documentation affecting hospital reimbursement.• Accurately and effectively identify missing documentation through clinical review and communicate with physicians and patient care teams regarding additional or more complete documentation opportunities.• Manage compliance with Medical Staff Rules and Regulations regarding documentation requirements, understanding coding and legal guidelines established by external regulatory agencies and following state and organization patient confidentiality policies.
Salary : $57 - $68
