The Documentation Specialist II works with physicians and other patient care providers to improve the quality of chart documentation so it accurately reflects the intensity of service and severity of illness. This role works collaboratively with coding staff, uses monitoring tools to track documentation improvement, and provides education and feedback to medical staff in one-on-one and group settings. The position also reports monthly activities to the Clinical Documentation Improvement Committee.
Key duties include:
- Collaborating with medical staff, nursing staff, coding staff, case managers, and other care providers to improve chart documentation quality
- Performing initial and follow-up chart reviews based on clinical judgment
- Reviewing medical records concurrently, including DRG assignment, complications, co-morbid conditions, and co-existing conditions
- Documenting findings using DRG worksheets, focus study entries, attestation sheets, and queries
- Interpreting clinical information such as diagnostic tests, medications, procedures, and nursing assessments
- Supporting the development of evidence-based physician order sets and protocols
- Accessing multiple software systems and integrating data from electronic medical record and coding/reimbursement systems
Requirements & Qualifications
Required qualifications:
- Associate or diploma degree in Nursing or Health Information Technology (HIT), or an advanced nursing or medical degree such as NP/APN or PA
- Current Registered Nurse license in the state of practice, RHIA, RHIT, or CCS required
- Licensure as a physician assistant, nurse practitioner/advanced practice nurse, or completion of medical school
- Two years of experience in critical care, medical or surgical inpatient care nursing, as an RN, PA, NP/APN, medical school graduate, or inpatient coder preferred
Preferred certifications:
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Professional (CDIP)
Benefits & Perks
Benefits and perks offered:
- No mandatory overtime
- Medical, dental, vision, PTO, life, and STD/LTD benefits starting on day one
- Daily Pay
- Retirement savings account with employer match
- Generous paid time off programs
- Employee referral incentive program
- Tuition and professional development reimbursement
- State-of-the-art equipment
- Supportive team approach
- Unlimited CEUs
Location
Indiana, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
3 weeks ago