Documentation Specialist

Documentation Specialist - Onsite Monday - Friday 8am-4:30pm Salary based on experience Job purpose Supports the agency in ensuring the patient health records contain quality documentation and coding that adhere to required standards and guidelines. Ensures documentation accurately reflects a comprehensive accounting of the care given to our patients as well as supports our billing practices. Acts as a liaison to bridge other departments through efficient means of communication and process improvement to yield a well-organized operation of data flow. Provides overall support to the Information Management department. Duties and responsibilities Chart Review & Quality Assurance : - Conducts quantitative and qualitative assessments of patient records to ensure completeness, consistency, timeliness, and accuracy using CAT auditing tools - Ensures integrity of the patient health record by providing oversight, training, monitoring, and support for paper and Electronic Health Record (EHR) and EHR related matters - Follows best practices and applicable standards from governing bodies when reviewing documentation and coding. - Collaborates with Medical and Clinical leaders to ensure patient chart documentation excellence Claims Coding and Process Improvement : - Implement strategies to enhance documentation quality across the organization - Performs weekly audits of documentation before billing, ensuring accuracy and communicating with staff as needed to resolve any discrepancies - Provides oversite of processes and procedures for maintaining accurate and timely claims processing and minimizing non-collectables - Provides internal audit and quality checks to ensure ethical coding and billing practices - Collaborates with Clinical and Medical leadership to ensure proper understanding of documentation requirements relating to coding and billing; provides or arranges training as necessary ** EHR System Support**: - Troubleshoots and resolves issues related to Electronic Health Record (EHR) systems and workflows, ensuring no barriers to quality documentation or patient care - Assists with the resolution of rejected claims in coordination with the billing team - Acts as the point of contact for documentation or technical challenges with the EHR system Reporting & Compliance : - Prepare reports on documentation quality for leadership and regulatory bodies - Ensures compliance with ethical coding and billing practices through internal audits and quality checks Training & Education : - Offers real-time support, training, and guidance to clinicians on documentation best practices - Educates and monitors new programs and staff, providing increased auditing to ensure quality documentation standards are met Documentation Improvement : Team Support & Professional Development : - Serves as a team member in Health Information Management (HIM) operations, offering insight into departmental procedures and projects - Participates in committees and works with external consultants to ensure compliance with documentation and billing standards - Supports personal growth by meeting development goals outlined in the Staff Development Plan Additional Duties : - Adapts to changing job duties as necessary based on agency needs Qualifications Associate's degree in Health Information Management (RHIT) or bachelor's degree in relatable healthcare studies (RHIA). Candidates without a degree may be considered (minimum o