Documentation Specialist II

Trinity Health • Mishawaka, IN

2d • Onsite

About The Position

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.

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.

Nice To Haves

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• 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.

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 the 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.

Benefits

• 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
• Unlimited CEU’s

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree