Documentation Specialist


New York, NY

5 - 7 years

Posted 232 days ago

This job is no longer available.

Job Responsibilities:

  • Assists with special projects as needed and perform related duties as assigned.
  • Provides feedback to physicians and other staff on the results of auditing and monitoring activities
  • Implements and participates in corrective action plans to ensure resolution of problem areas which are identified during internal or external auditing.
  • Serves as a resource to staff and physicians to obtain information or clarification on accurate and ethical reporting and documentation standards, guidelines and regulatory requirements
  • Participates in educational training programs regarding appropriate documentation required for complete and accurate coding and reporting.
  • Identifies opportunities for physician/practitioner education to improve documentation for severity of illness.
  • Coordinate final reporting of diagnoses with coding staff, providing clinical recommendations as needed.
  • Provides post discharge/pre-bill retrospective review of records in HIM for potential documentation improvement by applying concurrent standards of review and query processes.
  • Facilitates continuity of patient care by assisting in the screening process, making referrals and interacting with physicians and case management staff.
  • Reviews documentation for core measure standards and confers with the health care team to facilitate appropriateness of documentation.
  • Confers with coding staff and HIM leadership to review assignment of appropriate DRG and completeness of supporting documentation as needed.
  • Re-reviews medical records at discharge to identify responses to queries and validate documentation adequacy.
  • Logs all concurrent queries.
  • Maintains worksheets on all concurrent reviews
  • Consults a physician advisor when indicated by review results and/or query response
  • Interprets clinical information in the medical record (i.e. medications, vital signs, surgical outcomes, laboratory/diagnostic test results) to identify potential diagnoses.
  • Queries physicians for clarification and specificity of documentation in accordance with hospital policies and the AHIMA practice brief (Managing an Effective Query Process).
  • Applies knowledge of DRG documentation requirements to accomplish appropriate coding and to reflect accurate case mix index and clinical outcomes for the hospital.
  • Performs admission/continued stay review on assigned charts to include assignment of DRG, based on coding guidelines/regulations (i.e. AHA Coding Clinic, CMS, AHIMA), identification of complications and/or co-morbid conditions, and specific co-existing conditions.
  • Uses software and CDI tools to conduct concurrent review to evaluate documentation adequacy

Minimum Qualifications:
To qualify you must have be an RN, Coder, or Healthcare Professional
Bachelors degree required (for all hires after 2008)
Five years recent experience in adult medical/surgical acute care, utilization review, case management, or clinical documentation improvement.
Registered Nurse:
NY State Licensed RN or PA
CCDS preferred
Bachelors degree required (for all hires after 2008)
Three years recent experience as an inpatient coder.
Certificate from accredited coding school.
CCS, HRIT RHIA or CCDS preferred
Healthcare Professional:
Graduate education leading to MD, DO, or equivalent degree required
2-3 years experience in acute care, health care administration or commensurate experience
Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement

Job ID: 1039521_RR00018340