Healthcare Documentation Specialist

Healthcare Documentation Specialist

The Healthcare Documentation Specialist is responsible for improving the accuracy, completeness, and integrity of healthcare documentation to support quality patient care, compliant coding, and appropriate reimbursement. This role performs detailed medical record reviews, facilitates compliant queries, and delivers education to providers and clinical staff Supports the organization in fulfilling the mission, vision, and values of Logan Health.

Our Mission: Quality, compassionate care for all.

Our Vision: Reimagine health care through connection, service and innovation.

Our Core Values: Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence.

Qualifications:

• One or more of the following certifications required: CPC, CPMA, CDEO, CCS, RHIT, CCDS, or CDIP
• Minimum of 3–5 years of experience in coding, clinical documentation improvement (CDI), auditing, or related field required
• Knowledge of ICD-10-CM, CPT, HCPCS, and reimbursement methodologies (DRG, HCC, E/M) required
• Strong understanding of medical terminology, anatomy, and disease processes required
• Experience in provider-facing education or training required
• Clinical licensure preferred (e.g., RN or another licensed clinical professional)
• Experience in healthcare in an outpatient clinic setting or integrated health system environment preferred
• Familiarity with provider-based billing, value-based care and risk adjustment methodologies
• Experience with electronic health record (EHR) systems and reporting tools preferred
• Promotes excellence through setting high standards and providing high quality outcomes.
• Ability to act with integrity, kindness, and exhibit empathy.
• Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.
• Commitment to working in a team environment and maintaining confidentiality as needed.
• Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.
• Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
• Possess and maintain computer skills to include working knowledge of Microsoft Office Suite and ability to learn other software as needed.

Job Specific Duties:

• Performs concurrent and retrospective reviews of medical records to evaluate documentation quality, specificity, and completeness
• Identifies documentation gaps, inconsistencies, and opportunities for improvement
• Issues compliant queries to providers and clinical staff to clarify clinical documentation in accordance with organizational and regulatory standards
• Provides onsite and virtual education to providers and clinical staff regarding documentation best practices and coding guidelines
• Conducts one-on-one provider education and group training sessions tailored to specialty-specific needs
• Collaborates with coding, CDI, compliance, and revenue cycle teams to ensure alignment between documentation and coding
• Analyzes trends in documentation, denials, and audit findings; develops and implements improvement strategies
• Monitors and reports key performance indicators, including query response rates, documentation accuracy, and case mix index (CMI)
• Assists with internal and external audits, including preparation, education, and follow-up actions
• Maintains current knowledge of coding systems (ICD-10-CM, CPT, HCPCS), regulatory requirements, and payer guidelines
• Participates in departmental and organizational performance improvement initiatives

The above essential functions are representative of major duties of positions in this job classification. Specific duties and responsibilities may vary based upon departmental needs. Other duties may be assigned similar to the above consistent with knowledge, skills and abilities required for the job. Not all of the duties may be assigned to a position.

Maintains regular and consistent attendance as scheduled by department leadership.

Shift: Day Shift - 8 Hours (United States of America)

Location: Logan Health Medical Center – Kalispell, Montana

Schedule: Day Shift – 8 Hours | Full-Time – 40 Hours

Logan Health operates 24 hours per day, seven days per week. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.

Notice of Pre-Employment Screening Requirements

If you receive a job offer, please note all offers are contingent upon passing a pre-employment screening, which includes:

• Criminal background check
• Reference checks
• Drug Screening
• Health and Immunizations Screening
• Physical Demand Review/Screening

Equal Opportunity Employer

Logan Health is an Equal Opportunity Employer (EOE/AA/M-F/Vet/Disability). We encourage all qualified individuals to apply for employment. We do not discriminate against any applicant or employee based on protected veteran status, race, color, gender, sexual orientation, religion, national origin, age, disability or any other basis protected by applicable law. If you require accommodation to complete the application, testing or interview process, please notify Human Resources.