The Emergency Department Clinical Documentation Integrity Specialist shall support a designated hospital within the North East Division and be based within the Emergency Department. The position shall support providers with clinical documentation integrity efforts and level of care decision support.
This includes adherence to Emergency Room documentation best practices such as capture of all clinically relevant aspects of the patient encounter including laboratory, radiologic, and other test results. Ensure the Emergency Room medical record accurately captures the process of evaluation, management, medical decision making, and medications, past history, disposition, and clinical assessment and/or diagnoses. Efforts shall include education on more specific or specified conditions versus those sign/symptom or unspecified conditions.
The position shall utilize criteria to confirm medical necessity for appropriate level of care settings. The Emergency Department Clinical Documentation Integrity Specialist shall provide education to providers on areas of documentation opportunities.
Key ResponsibilitiesReview of Emergency Room medical records Provide documentation integrity support to Emergency Room providers Identify high risk patients of incorrect level of care utilizing specific criteria Conduct real-time admission reviews based on appropriate utilization criteria established by standards, procedures, and/or polices