Senior Documentation Specialist

Position Summary Review / Audit practice medical records and coding of practice providers, to ensure proper coding completed and to ensure compliance with regulatory agencies.

Assign ICD-10, CPT, or HCPCS codes to accurately capture clinical data elements according to regulatory guidelines and hospital rules and regulations.

Abstracts other data elements as required. Assist with coding inpatient, ambulatory, surgery, observation encounters. Assist with educating coding staff, providers and management, setting standard of coding quality, and provide educational tools and sessions.

Develop and maintains coding guidelines in accordance with Official Coding Guidelines, disseminate and educate others on documentation requirements.

Provide coder education on current best practices, changes, issues. Provide Clinician coding and documentation orientation and semi annual reviews.

Share information and seeks ways to add value both to the customer and to the team. Assist and mentor non-certified and or junior coders.

Partner with administration on compliance related projects that documentation.

• Education Associates of Health Information Administration - Preferred
• Experience 5-7 Years Coding, Healthcare Accounting - Required
• License & Certification Professional Certification - Required CPC - Required CPMA preferred at hire, but required within 365 days of hire.

Preferred : One or more specialty coding certifications preferred (Cardiology, Cardiothoracic, OBGYN, Podiatry, etc) Other preferred : CDEO, CCC, CEMC, CIC, CCS, RHIT, CCS-P, or RHIA

Core Job Functions Provides coding 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 a 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 review and friendly internal audits of coding and documentation from billing office, inpatient provider visits, outpatient and professional service setting, and follow-ups as needed with education plans and gaps analysis.

Have ability to teach regarding prospective and retrospective visits. Teach providers regarding errors and concerns, and escalate concerns as appropriate.

Audits medical records to ensure proper coding completed and to ensure compliance with federal and state regulatory agencies.

Evaluates medical records for documentation consistency and adequacy. Provides coding support two or more specialties / sub specialties.

Provides patient outreach regarding rejected claims or procedures, while exhibiting effective communication skills and protecting confidentiality.

Monitors workflow and daily unbilled reports to determine if turnaround time is within goal. Prepares a goal status spreadsheet daily and distributes to co-coworkers.

Provides coding guidance to co-workers when needed. Provide new hire coding audits and training. Provide annual audit reviews with providers.

Create teaching tools, and develop and maintain internal logs outlining internal audits in secure area. Makes recommendations for data quality improvements and revenue enhancements with practice management.

Interact and educate coding staff, providing feedback to the coding management team and staff regarding highly complex 10 CM / PCS and CPT-4 coding and DRG / APC assignment and related clinical documentation.

Reviews reports from hospital to verify all charges were entered into billing system.