Documentation Specialist

American Addiction Centers • Rome, GA

20h • $38 - $56

About The Position

Reviews Medicare inpatient medical records to ensure appropriate documentation of co-morbidities and complicating diagnoses. Manages daily work list of patients meeting priority list diagnoses for documentation improvement including top volume/variance DRG pairs, Pneumonia (DRG089, Respiratory (DRG 079), Sepsis (DRG 320, 321, and 416). Queries appropriate physician for necessary documentation. Follows-up to ensure query response from physician. Maintains database on queries, response to query and documentation outcomes. Uses database reports to identify physician education needs and to report on success of documentation program. Develops and provides education programs to appropriate providers. Acts as a resource to the Utilization Managers for early assignment of a working DRG on all Medicare patients. Provides education/training to other UM staff to maintain a backup to the documentation specialist in case of time off. Coordinates patient care throughout inpatient or observation stays. Actively participates in Performance Improvement (PI) processes. Actively participates in departmental and organization-wide Lean/Six Sigma program 100 day workouts. Maintains workload to ensure progress towards departmental goals and objectives. Identifies, documents and reports variances, quality, cost and risk issues to management. Supports and participates in the review and modification of policies, procedures and processes. Performs other related duties as assigned.

Requirements

• Valid, active unencumbered Nursing license approved by the Georgia Licensing Board
• Graduate of an accredited School of Professional Nursing
• 5 or more years hospital experience caring for short term acute patients
• Comprehensive understanding of reimbursement mechanisms
• Full range of body motion including handling and lifting patients, manual and finger dexterity and eye-hand coordination.
• Standing and walking for extensive periods of time.
• Occasionally lifts and carries weight up to 50 pounds.
• Ability to distinguish letters, numbers and symbols with vision and hearing within normal range to respond to Code alerts and equipment alarms.
• Work-related stress due to volume and time constraints with irregular working hours.

Nice To Haves

• HIM/Coding certification preferred
• BSN or MSN Preferred

Responsibilities

• Reviews Medicare inpatient medical records to ensure appropriate documentation of co-morbidities and complicating diagnoses.
• Manages daily work list of patients meeting priority list diagnoses for documentation improvement including top volume/variance DRG pairs, Pneumonia (DRG089, Respiratory (DRG 079), Sepsis (DRG 320, 321, and 416).
• Queries appropriate physician for necessary documentation.
• Follows-up to ensure query response from physician.
• Maintains database on queries, response to query and documentation outcomes.
• Uses database reports to identify physician education needs and to report on success of documentation program.
• Develops and provides education programs to appropriate providers.
• Acts as a resource to the Utilization Managers for early assignment of a working DRG on all Medicare patients.
• Provides education/training to other UM staff to maintain a backup to the documentation specialist in case of time off.
• Coordinates patient care throughout inpatient or observation stays.
• Actively participates in Performance Improvement (PI) processes.
• Actively participates in departmental and organization-wide Lean/Six Sigma program 100 day workouts.
• Maintains workload to ensure progress towards departmental goals and objectives.
• Identifies, documents and reports variances, quality, cost and risk issues to management.
• Supports and participates in the review and modification of policies, procedures and processes.
• Performs other related duties as assigned.

Benefits

• Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:
• Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance
• Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 11-50 employees