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Documentation Specialist
Last Modified:12/11/2019
| Job Code |
107C3 |
| Job Title |
Documentation Specialist |
| Department Code |
100905 |
| Department Name |
Coordinated Care |
Template Used: I
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
LICENSURES OR CERTIFICATIONS REQUIRED
- Valid, active unencumbered Nursing license approved by the Georgia Licensing Board
- LICENSURES OR CERTIFICATIONS PREFERRED
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.
Total Score: 0
Total Possible Score: 0 |
