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Documentation Specialist- Admission Discharge Transition Unit-Days

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Rome, GA, United States
Job ID: 78078
Job Family: Nursing
Status: Full Time
Shift: Day
Detailed Shift and Schedule: Weekdays 8-4:30
Job Type: Regular
Department Name: 12311112531528-Nursing - Admission Discharge Transition Unit



The Documentation Specialist is responsible for reviewing all Medicare inpatient medical records to ensure appropriate documentation of co-morbidities and complicating diagnoses. The Documentation Specialist will work as a cooperative team player with HIM coding staff to ensure understanding of coding rules and methodologies that impact DRG assignment. Once variance from appropriate documentation is identified, the Documentation Specialist makes certain that appropriate education and follow-up occurs with the appropriate provider or provider group to ensure compliance.


A. Education

1. Graduate of an accredited School of Registered Professional Nurses or Licensed Practical Nursing; BSN preferred, MSN encouraged

B. Experience

1. Minimum of five years of hospital experience in the care of short term acute patients

2. Comprehensive understanding of reimbursement mechanisms

3. Demonstrated ability to communicate with physicians

4. HIM/Coding certification encouraged

5. Participation in chart review and medical record coding encouraged

C. Licensure/Certification

1. Current license/registration to practice as a registered nurse or licensed practical nurse in the state of Georgia