Senior Documentation Specialist

Senior Documentation Specialist

Position Summary

• Reviews documentation and coding of practice providers to identify opportunities in provider documentation, ensure proper coding, and compliance with regulatory agencies.
• Identifies appropriate E / M levels, ICD-10, CPT, and / or HCPCS codes that accurately reflect clinical elements according to regulatory guidelines and hospital rules and regulations.
• Assists with educating coding staff, providers, and management, setting standard of coding quality, and providing educational tools and sessions.
• Provides guidance and education on SJC coding policies and procedures.
• Provides coder education on current best practices, changes, and issues.
• Provides clinician coding and documentation orientation and semi-annual reviews.
• Functions as a source of expertise and direct resource for clinicians to discuss documentation accuracy, rules, and improvement.
• Serves as liaison between clinicians and coding team.
• Shares information and seek ways to add value to the team.
• Assists and mentors non-certified and / or junior coders.
• Partners with administration on compliance related projects regarding documentation.
• This position is a Hybrid position that does require in office work each week.

Education

None Required

Experience

5-7 Years Professional Coding - Required

Healthcare Accounting is a plus

License & Certification

Professional Certification; CPC or CCS-P - Required

CPMA Preferred at hire, and Required within 365 days of hire.

One or more specialty coding certifications preferred (Cardiology, Cardiothoracic, OBGYN, Oncology, etc) - Preferred

Other preferred : CDEO, CCC, CEMC, CIC, CCS, RHIT, CCS-P, or RHIA

Core Job Functions

Reviews documentation and coding to identify opportunities and to ensure compliance with federal and state regulatory agencies. Evaluates medical records for documentation consistency and adequacy.

Develops and implements a method by which each physician has a representative sample of his / her medical records reviewed on a routine and frequent basis.

Provides education using adult learning methods to coders, physicians, medical staff, management, and others regarding complex documentation, coding, reimbursement, outpatient, and professional coded data. Plans and hosts one-on-one and workshop education forums, as warranted.

Serves as an expert level coding resource, acting as a liaison among all department managers, staff, physicians, and administration with respect to coding and documentation issues.

Conducts quality reviews of coding and documentation from billing office, inpatient provider visits, outpatient, and professional service setting, and follows up as needed with education plans and gap analysis. Educates on differences and process of prospective and retrospective visits. Teaches providers regarding errors and concerns and escalate concerns as appropriate.

Focuses on root cause identification and process improvement specific to documentation accuracy and completeness.

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