LOUBEL ROBLES MCCARTER

• Perform daily, weekly and monthly QA audits and reviews to CDI specialist (reviewer) and ensure that production process are controlled and monitored for quality and compliance.
• Identify and provide resolution to workflow and production issues in coordination with operations and training.
• Maintain documentation of weekly and monthly quality audit reports and collaborate with operations and training for identified areas that need improvements and re-education.
• Performs one-on-one and/or triad QA coaching sessions to concern CDI specialist.
• Discuss QA audit findings and provides mentorship to CDI specialist.

• Educate patients, families and caregivers about the condition of renal disease and the treatment plan.
• Supervise the dialysis treatment from beginning to end, including priming the dialyzer and bloodlines.
• Record the patient's vital signs and medical details.
• Manage the care of multiple dialysis patients throughout their treatment.
• Identify unusual dialysis reactions, and quickly notify appropriate medical professionals.
• Collect blood work and other laboratory tests according to instructions.
• Schedule dialysis treatments.
• Work with dialysis technicians to ensure the correct setup and operation of dialysis equipment and devices.

• Improved documentation by reviewing specific conditions assigned by the client.
• Identify cases with clinical indicators that may require provider documentation clarification and/or specificity.
• Increased efficiency by reviewing the chart on a daily basis.
• Educate providers about identifying the disease process that reflect SOI, complexity and acuity in order to facilitate accurate application of code sets.
• Clinically evaluate how the health record translates into coded data, including review of provider and other clinician documentation, lab results, diagnostic information and treatment of plans.

Designation: Obs/IP Coder, DRG Auditor, OP coder

• Determine and assign the principal and secondary ICD-10 CM diagnosis codes, in addition to present on admission indicators, and ICD-10 PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiologic disease processes.
• Analyze code assignment and sequence to assure proper DRG assignments; sequence codes in compliance with ICD-10 Official Coding Guidelines, UHDSS and other regulatory requirements to accurately assign the DRG.
• Reviews, analyze and interpret patients entire medical records to identify the most specific and accurate ICD-10 diagnosis and procedure codes during a hospital encounter.
• Analyze the medical record documentation for complications and comorbidities.

• Identifies and assigns the appropriate primary diagnosis code in accordance with coding guidelines and ED coding standards.
• Identifies and assigns secondary diagnosis codes based on the specificity of clinical findings (i.e. laboratory, radiology and pathology reports, as well as clinical studies) in support of existing clinical diagnosis.
• Identifies and assigns the appropriate Evaluation and Management (E&M) code.
• Identifies and assigns the appropriate Critical Care services code, when applicable.
• Identifies and assigns the appropriate procedure codes in accordance with charging guidelines and ED coding standards.