HIMCDISpecialist

# **Primary Location:** Ambulatory Care Building - UMC # **Address:** 550 South Jackson St.Louisville, KY 40202 # **Shift:** First Shift (United States of America) # **Job Description Summary:** # **Job Description:** **Job Summary** This position is responsible for reviewing patient medical records to facilitate modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team to promote accurate capture of clinical severity of illness and risk of mortality (later translated into coded data) and to support the level of service rendered to relevant patient populations. CDIS exhibits expert knowledge of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or CCs), and quality-driven patient outcome indicators. Interacts as needed with internal customers to include but not limited to hospital staff, physicians, and other revenue cycle team members. Actively participates in department and hospital performance initiatives when needed to ensure ULH success. # **Additional Job Description:** **Responsibilities** * Completes initial medical record reviews of all inpatient patient accounts (all payers) within 24-48 hours of admission for a specified patient population to: * **(a)** Evaluate and review inpatient medical records daily, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation. * **(b)** Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, score risk of mortality and severity of illness and initiate a review worksheet. * **(c)** Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary. * Formulate clinically, compliant and credible physician queries regarding missing, unclear or