• Provide timely reviews of patient medical records to ensure accurate and complete documentation • Work with providers and coders to ensure documentation reflects the complexity of the patient • Ensures inpatient clinical documentation accurately reflects severity of illness (SOI) and Risk of Mortality (ROM) • Ensures Present on Admission (POA) clinical conditions are documented accurately • Ensures documentation reflects accurate safety rating scores and quality of care scores (PSIs) • Participate in education sessions and feedback to coders, CDI Reviewers, and Hospital Quality Departments • Conduct regular audits using standardized methodology to ensure compliance • Tracks and trends data for use by the HIM Documentation Quality and Education Manager • Escalates any observed issues which may impact quality of documentation or coding • Ensures that coding and DRG assignment is in compliance with CMS rules and regulations