Documentation Specialist - Admission Discharge Transition Unit

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.