Documentation Specialist

Documentation Specialist

Last Modified:12/11/2019

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POSITION SUMMARY

• The Documentation Specialist reviews Medicare inpatient medical records to ensure appropriate documentation. He/she works with HIM coding staff to ensure understanding of coding rules and methodologies and makes certain that appropriate education and follow-up occurs with providers to ensure compliance.

QUALIFICATIONS

• EDUCATION REQUIRED
• Graduate of an accredited School of Professional Nursing
• EDUCATION PREFERRED
  • BSN or MSN
• 
  LICENSURES OR CERTIFICATIONS REQUIRED
  • Valid, active unencumbered Nursing license approved by the Georgia Licensing Board
• LICENSURES OR CERTIFICATIONS PREFERRED
  • HIM/Coding certification
• 
  EXPERIENCE REQUIRED
  • 5 or more years hospital experience caring for short term acute patients
  • Comprehensive understanding of reimbursement mechanisms
• EXPERIENCE PREFERRED
  • Participation in chart review and medical record coding

ROLE SPECIFIC ESSENTIAL DUTIES AND RESPONSIBILITIES

• Reviews Medicare inpatient medical records to ensure appropriate documentation of co-morbidities and complicating diagnoses.
  • Manages daily work list of patients meeting priority list diagnoses for documentation improvement including top volume/variance DRG pairs, Pneumonia (DRG089, Respiratory (DRG 079), Sepsis (DRG 320, 321, and 416).
  • Queries appropriate physician for necessary documentation.
  • Follows-up to ensure query response from physician.
  • Maintains database on queries, response to query and documentation outcomes.
  • Uses database reports to identify physician education needs and to report on success of documentation program.
  • Develops and provides education programs to appropriate providers.
  • Acts as a resource to the Utilization Managers for early assignment of a working DRG on all Medicare patients.
  • Provides education/training to other UM staff to maintain a backup to the documentation specialist in case of time off. Coordinates patient care throughout inpatient or observation stays.
• Actively participates in Performance Improvement (PI) processes.
  • Actively participates in departmental and organization-wide Lean/Six Sigma program 100 day workouts.
  • Maintains workload to ensure progress towards departmental goals and objectives.
  • Identifies, documents and reports variances, quality, cost and risk issues to management.
  • Supports and participates in the review and modification of policies, procedures and processes.
• Performs other related duties as assigned.

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