• This position is responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation • 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 • 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