Documentation Specialist II

About the Role

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 collaborate with coding staff, utilize monitoring tools to track documentation accuracy, and provide education and feedback to medical staff in one-on-one and group settings. The role reports activities monthly to the Clinical Documentation Improvement Committee.

Responsibilities

• Actively demonstrates the organization’s mission and core values and conducts oneself in a manner consistent with these values.
• Adheres to all laws and regulations pertaining to patient health, safety, and medical information.
• Interacts collaboratively with medical staff, nursing staff, coding staff, case managers, and other patient care providers to improve documentation quality.
• Performs initial and follow-up case reviews based on clinical judgment.
• Conducts concurrent reviews of medical records, including DRG assignment, identifying complications, comorbidities, and specific coexisting conditions.
• Documents findings in formats such as DRG worksheets, occurrence reports, coding attestation sheets, and queries.
• Accurately interprets clinical information in medical records, including diagnostic tests, medications, procedures, and nursing assessments.
• Assists in developing evidence-based physician order sets and protocols.
• Proficiently accesses and integrates data from multiple software systems, including Electronic Medical Records and Coding and Reimbursement software.
• Performs other duties as directed.

Requirements

• Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an advanced degree in nursing or a medical field (e.g., NP/APN, PA).
• Current licensure as a Registered Nurse (RN), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Physician Assistant (PA), or Nurse Practitioner/Advanced Practice Nurse (NP/APN), or completion of medical school.
• 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, PA, NP/APN, medical school graduate, or inpatient coder preferred.

Benefits

• No mandatory overtime.
• Benefits starting on the first day of employment, including medical, dental, vision, PTO, life, and short-term/long-term disability insurance.
• Daily Pay option.
• Retirement savings account with employer match.
• Generous paid time off programs.
• Employee referral incentive program.
• Tuition and professional development reimbursement.
• Unlimited continuing education units (CEUs).