Document Imaging Specialist

Job Summary:

Responsible for improving the overall quality and completeness of clinical documentation.  Facilitates modifications to clinical documentation through interaction with physicians, nursing staff, medical records coding staff and other essential patient caregivers to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer.   Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.  Educates all members of the patient care team on an ongoing basis.

Essential Functions:

• Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service provided to all patients with a DRG based payer.
• Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements and referral policies and procedures.
• Improves the overall quality and completeness of clinical documentation by performing admission/ continued stay reviews using Compliant Documentation Program Management (CDMP) guidelines.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and organizational outcomes.
• Interacts with Case Managers and Nurses to ensure the level of care provided to the patients is accurately reflected in the documentation.
• Process discharges by updating the DRG Worksheet to reflect any changes in status, procedures / treatments, and conferring with physician to finalize diagnoses.
• Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Reviews clinical issues with coding staff to assign a working DRG.
• Assists with management of CDMPTrack .
• Serves as a member of the CDMP Task Force
• Assists with special projects.
• Provides program updates to Steering Committee on a routine basis.
• Advises Director of immediate challenges that have a negative impact on the program functions.
• Performs other duties as assigned.

Other Duties:

• Good critical thinking skills, able to assess, evaluate and teach.  Flexible with a working knowledge of adult medicine.  Sight and hearing.
• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication.  Professional, team player, able to communicate well with all levels of staff.  Strong interpersonal skills, pleasing personality, positive demeanor.
• Performs other duties as assigned.

Minimum Education/Certifications:

RN, BSN preferred.  Current license as a Registered Nurse.

Minimum Work Experience:

5 years recent clinical experience in a hospital setting or 4 years recent clinical experience and 2 years of ICD-9 coding experience.  Utilization Review or coding experience preferred.