Clinical Documentation Medical Professional Lead - Clinical Documentation Integrity

Georgia Orthopaedic Society
US - Texas - San Antonio
July 1, 2024

Description
Summary:
The Clinical Documentation Medical Professional (CDMP) Lead is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDMP Lead will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDMP Lead will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers, and health information management coding staff to ensure that reimbursement (reflecting the proper quality of care and appropriate reimbursement) is received for the level of services rendered to the patients. Offers guidance and support to RN Clinical Documentation Specialists and assists the Director as needed.
Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
Maintains consistency with Administrative and Departmental policies with appropriate behavior, dress, attitude, attendance, confidentiality, professionalism, and reliability.
Concurrently reviews selected admissions to identify the most appropriate principal and secondary diagnosis to accurately reflect the patient's severity of illness.
Communicates with physicians and clinicians regarding missing, unclear, or conflicting medical record documentation to clarify and obtain needed documentation.
Develops clinician or physician education strategies to promote complete and accurate documentation and correct negative trends.
Confers with Coders concurrently to ensure appropriate DRG and completeness of supporting documentation.
Develops tools and coordinates and performs audits for compliance.
Gathers and analyzes information pertinent to documentation findings and outcomes.
Identifies patterns and trends variance, identifying opportunities for improvement.
Research literature to identify new methods in development for disease components and documentation.
Supports and is involved with ongoing continuing education for both associates and physicians.
Performs audits as directed timely and efficiently.
Works with Director to enhance relationships and work closely with other departments and associates.
Strategizes and helps implement workflow processes that will impact department metrics to also include regional initiatives.
Works independently with little to no supervision.
Will identify areas of improvement and provide suggestions for resolutions.
Other duties as assigned.
Requirements:
One of the following required
Foreign or domestic Medical School Graduate (license not required)
Graduate from a Physician's Assistant program
Graduate from a Registered Nurse program
5+ years of experience in the area of population to be served is required
M.D. or D.O.; ECFMG certification (preferred for Foreign Medical Graduates)
Current PA or RN license required, as appropriate.
Certified Clinical Documentation Specialist (CCDS) required
Work Type:
Full Time
EEO is the law - click below for more information:
/eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf
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