Clinical Documentation Specialist - Northwell Health : Job Details

Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided. Responsible for concurrent inpatient medical record reviews for Medicare, Medicaid and all commercial payers. Generates queries and have follow up discussions with physicians for clarification of ambiguous or conflicting documentation. Job Responsibility 1. Facilitates clarification of clinical documentation ensuring accuracy and integrity in the medical record .. Facilitates appropriate clinical documentation to support diagnosis coding and ensure the appropriate level of service is recorded .. Works with physicians on assigned patient care units to clarify clinical documentation in the patients medical record through a concurrent review process throughout the patients inpatient stay. 4. Requests clarification of clinical documentation from the physician(s) on a concurrent basis...Clinical, Specialist, Healthcare, Medical, Patient