Documentation Specialist II

Documentation Specialist II

The Documentation Specialist II works with physicians and other patient care providers to improve the quality of chart documentation to accurately reflect intensity of service and severity of illness. They work collaboratively with coding staff. They utilize monitoring tools to track the progress of the documentation accuracy program. They provide education and feedback to the medical staff one-on-one and in-group settings regarding documentation. The Documentation Specialist II reports activities monthly to the Clinical Documentation Improvement Committee.

Job responsibilities:

• Actively demonstrates the organization's mission and core values and conducts oneself at all times in a manner consistent with these values.
• Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information. Demonstrates behaviors consistent with identified competencies and job requirements
• Interacts collaboratively with medical staff, nursing staff, coding staff, case managers, and other patient care providers to improve the quality of chart documentation to accurately reflect level of services provided.
• Performs initial case reviews and appropriate follow-up reviews based on judgment of clinical picture.
• Performs concurrent review of all components of the medical records of specified patient population to include assignment of DRG, identifying complications and co morbid conditions, and specific co-existing conditions.
• Documents findings in appropriate format based on need to communicate the information to the medical staff or coding. The format may include any or all of the following: DRG worksheets, Occurrence Reporting System focus study entries, coding and reimbursement preliminary attestation sheets and queries.
• Accurately interprets clinical information in the medical record including diagnostic tests, medications, procedures, and nursing assessments.
• Assists in the research and development of evidence-based physician order sets and protocols.
• Proficient in accessing multiple software systems and integrating data from all systems including Occurrence Reporting System application, Electronic Medical Record, and the Coding and Reimbursement software.
• Performs other duties consistent with purpose of job as directed.

Requirements:

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.
• Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA) Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) required,
• Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Experience: Two (2) years of experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.

Why Saint Joseph Health System?

At Saint Joseph Health System, our values give us strength. That character guides every decision we make - even when those decisions are complicated, costly or hard. We honor our mission to care for every man, woman and child who needs us by investing in technology, people and capabilities that allow us to set the standard for quality care.

What we offer:

• NO mandatory overtime
• Benefits first day of employment (Including: Medical, Dental, Vision, PTO, Life, STD/LTD)
• Daily Pay
• Retirement savings account with employer match
• Generous paid time off programs
• Employee referral incentive program
• Tuition/professional development reimbursement
• State of the art equipment
• Supportive team approach
• Unlimited CEU's

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.