COMMUNITY MEDICAL CENTER HEALTHCARE SYSTEM

JOB DESCRIPTION / PERFORMANCE APPRAISAL

Title:

Documentation Specialist

Job Code:

Department Assigned:

Medical Records

Cost Center:

20870

POSITION SUMMARY

Conducts clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation of acute care services. Performs chart reviews to look for educational opportunities to improve documentation by the physicians and ancillary staff. Works closely with physicians and medical staff to facilitate appropriate physician documentation of patient care. Plays a key role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

QUALIFICATIONS

Education: CCS, RHIT, RHIA preferred but not required; equivalent experience will be considered in lieu of degree.

Experience: Minimum three (3) years coding experience in an acute care setting

Specific Requirements: Knowledge of care delivery documentation systems, DRG/APC methodology, and related medical record documents. Knowledge of the elements of disease processes and related procedures, pathology and pharmacology. Strong broad-based clinical knowledge and understanding of pathology/physiology or disease processes. Excellent written and communication skills. Excellent critical thinking skills. Excellent interpersonal skills to build effective partnering relationships with physicians, coding staff, nursing staff and hospital management staff. Must be flexible and a team player. Working knowledge of inpatient admission criteria.