Documentation Specialist

• Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI).
• Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff.
• Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient’s clinical status and care.
• Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.

• Organizational, analytical, and writing skills
• Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills
• Excellent time management
• Effective and appropriate communication with physicians & coding professionals
• Knowledge of regulatory guidelines
• Knowledge of Medicare Part A and MS-DRG and/or APR-DRG payment methodologies
• Ability to pass a written clinical competency assessment
• Basic computer skills

• A Bachelor of Science degree in Nursing or International Medical Graduate.
• Must possess Minimum 5 years of acute care hospital experience
• AHIMA CCA or CCS certification preferred
• ACDIS CCDS or AHIMA CDIP certification preferred
• Minimum 2 years of Inpatient Coding experience with ICD-10 CM/PCS.
• CDI experience preferred

Richmond University Medical Center