- Medical Record Review: Analyze inpatient and outpatient documentation for completeness, accuracy, and specificity.
- Handling Queries: Issue compliant queries to physicians for clarification on diagnoses, procedures, or clinical indicators.
- Coding Collaboration: Work closely with coding teams to ensure proper DRG assignment and coding compliance.
- Technology Utilization: Use CDI software and EHR systems to conduct reviews and track performance.
- Interdisciplinary Collaboration: Partner with case managers, HIM professionals, and clinical teams to ensure documentation reflects the full scope of care.