• Collaborating with internal and external clients, supporting and enabling effective and efficient communication that results in operational excellence. • May serve as a primary writer who creates and provides input on routine deliverables, such as medical information documents. • Ensures compliance with applicable SOPs, WI, quality processes, and requirements for documents. • May assist in determining best practices for achieving optimal results. • May assist in program management activities. Duties could include developing timelines and budgets for assigned deliverables and tracking deliverable metrics.

• Completes patient medical record reviews to support compliance audits, organizational risk assessments, and ongoing monitoring activities. • Responsible for reviewing and determining that supporting documentation demonstrates performance of medically necessary services. • Supports random and focused pre-payment and post payment audits in the review of patient medical records. • Completes medical record reviews in a timely manner. • Assists to ensure all possible efforts are made to obtain appropriate internal and external patient medical record documentation to support the services provided and billed. • Supports the tracking of medical documentation received, outbound requests, and ensures all necessary information is obtained (where they exist). • Follows related policies and procedures and escalates where appropriate. • Assists in medical review related customer chart documentation trend analysis for outreach training and education opportunities. • Ensures all reasonable efforts are made to obtain appropriate external medical record documentation to support the services in question. • Ensures medical record documentation received is recorded appropriately and aids in the management of outbound documentation requests. • Assists Senior Clinical Specialist with other areas of responsibility as requested.

• Facilitate improvement in the overall quality, completeness, and accuracy of medical record documentation • Educate and train of the Clinical Documentation Integrity team through extensive audit investigation, clinical criteria research, and data analysis • Develop and deliver a formalized CDI orientation process • Draft and submit written queries to providers to clarify documentation • Collaborate with Coding, HIM, Patient Safety and Quality, Enterprise Compliance Services, and Revenue Integrity • Perform complex clinical documentation of designated patient records to assess accuracy • Develop and perform an internal auditing process in partnership with the CDI Manager to validate query compliance • Educate providers, coder, and CDI team regarding clinical documentation concepts, health data, quality outcomes, and compliance regulations.

• This position is responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of physician documentation. • This position facilitates modifications to clinical documentation through concurrent interaction with physicians (face-to-face and electronically) and other members of the health care team. • The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding. • Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients. • Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes. • Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG. • Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system. • Gathers and analyzes information pertinent to documentation findings and outcomes. • Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization. • Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. • Identifies patterns, trends variances and opportunities to improve documentation review and process. • Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement. • Assists in the development and reporting of performance measures to the medical staff and other departments and prepares physician specific data information. • Conferences with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation. • Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness. • Documents conference and results. • Attends various hospital service line meetings, reviewing outcome information, and educating physicians on service line specific improvement opportunities. • Complies with HIPAA and Code of Conduct policies. • Assists with special projects as needed. • Demonstrates competency for individual performance and development in the following areas: Customer Service, Job Skills, Resource Management, Teamwork, and Innovation. Directors shall determine percentage weight distribution for each competency category. • Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service. • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff. • Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences.