The Documentation Specialist is responsible for improving physician documentation in the medical record by performing concurrent medical record reviews and addressing incomplete documentation with physicians and clinical staff. This individual also indirectly affects the case mix index as well as helps to ensure DRG assignment and severity and mortality profiles are accurately reflected in the medical record.
Reconciles cases routinely in conjunction with collaborative efforts with HIM management and coding staff. Interacts with case managers in assisting in determining geometric mean length of stay on patients reviewed to assist in discharge targets and patient throughput.
Must be a registered nurse in the State of Illinois with a minimum of 5 years acute care nursing preferred. Knowledge of POA/DRG and ICD-9-CM coding is a plus. Must have excellent organization, analytical, problem solving and oral and written communication skills to appropriately interrelate with hospital departments and medical and clinical staff. This position requires the individual to be comfortable interacting with physicians on a daily basis and be willing to clarify physicians' documentation in the medical record with the physician in a highly professional/respectable manner.