- Related course work is required
Under minimal supervision; reviews inpatient medical records facilitating improvement in the overall quality and completeness of medical record documentation. Obtains appropriate clinical documentation through extensive interaction and collaboration with physicians, nursing staff, other patient caregivers. Collaborates with Health Information Management coding staff to ensure that documentation supports the diagnosis and justifies the treatment rendered. Ensures the clinical information utilized in profiling and reporting outcomes is complete and accurate. Collaborates with the Case Management Physician Liaison to develop educational sessions for physicians.
Requirements: Minimum five (5) years clinical experience adult inpatient med-surg or critical care. Utilization Review, case management, or coding experience preferred. RN- Graduate of an accredited school of nursing -OR - Physician Asst. Graduate of an approved Physician Asst. program. -OR - Nurse Practitioner-Graduate of an accredited school of nursing and graduate of a Nurse Practitioner program. -OR- Physician- graduate of an accredited Physician program -OR- Health Information Administrator Bachelor�s degree in Health Records Administration.
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