Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided

Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity

Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rationale for the recommendations

Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality

Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination

Provides face-to-face educational opportunities with physicians on a regular basis

Provides complete follow through on all requests for clarification or recommendations for improvement

Leads the development and execution of physician education strategies resulting in improved clinical documentation

Ensures effective utilization of Optum® CDI 3D Technology to document all clarification activity

Utilizes only the Optum360 approved clarification forms