Clinical Documentation Specialist, First Reviewer
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About The Position
The Clinical Documentation Specialist performs concurrent analytical reviews of clinical and coding data to improve physician documentation for all conditions and treatments from point of entry to discharge. This role ensures an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. The specialist facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaboration with coding professionals is essential to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.
