Clinical informatics is a unique field within the health care sector that requires one to work with data and technology to improve health care services. My dream job is to be a clinical informatics analyst. My major focus will be on coding and billing which are two critical components of medical care services. Coding and billing processes require skilled professional to read, interpret, track and record medical information (Sewell, 2018). Coding captures information related to diagnoses, treatment, procedures, medication, and equipment that are translated into alphanumeric codes. Information comes from different sources such as medical notes, electronic records, and lab results among other important data. My role will be crucial in transferring these codes from various sources to the billing system and patient records (Sewell, 2018). Coding is an important process that requires accuracy because the data will be submitted for medical claims. Coding needs to be done with exactness because it can impact on medical care, more so if it relates to insurance reimbursement, hence, proper coding will lead to appropriate payment.
2. What kinds of ideas would you have to organize process and documentation to assist with revenue and/or quality metrics based off of coding?
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I would recommend the implementation of Clinical documentation improvement (CDI) program as a strategy to improve documentation to improve revenue. The first step of the program is to conduct a gap analysis to identify existing document problems in different sections. Understanding documentation and coding challenges will help in identifying revenue leakage (Sewell, 2018). Part of the clinical documentation improvement process will be to introduce an automated clinical documentation process by selecting appropriate CDI software that would guide the organization and help keep track of the daily medical routines. The organization needs to conduct staff orientation and continuous improvement education. With evolving health care policies and claim reimbursement rules, ongoing education for staff working within the medical record is key to sustain documentation improvement.
Reference
Sewell, J. (2018). Informatics and Nursing . New York, NY: Lippincott Williams & Wilkins.
