Documentation Specialist

Documentation Specialist 

Monday - Friday 8am-4:30pm 

Job purpose

Supports the agency in ensuring the patient health records contain quality documentation and coding that adhere to required standards and guidelines. Ensures documentation accurately reflects a comprehensive accounting of the care given to our patients as well as supports our billing practices.  

 Acts as a liaison to bridge other departments through efficient means of communication and process improvement to yield a well-organized operation of data flow. Provides overall support to the Information Management department. 

 Duties and responsibilities

Chart Review & Quality Assurance:

• Conducts quantitative and qualitative assessments of patient records to ensure completeness, consistency, timeliness, and accuracy using CAT auditing tools
• Ensures integrity of the patient health record by providing oversight, training, monitoring, and support for paper and Electronic Health Record (EHR) and EHR related matters 
• Follows best practices and applicable standards from governing bodies when reviewing documentation and coding.
• Collaborates with Medical and Clinical leaders to ensure patient chart documentation excellence 

Claims Coding and Process Improvement:

• Implement strategies to enhance documentation quality across the organization
• Performs weekly audits of documentation before billing, ensuring accuracy and communicating with staff as needed to resolve any discrepancies
• Provides oversite of processes and procedures for maintaining accurate and timely claims processing and minimizing non-collectables
• Provides internal audit and quality checks to ensure ethical coding and billing practices
• Collaborates with Clinical and Medical leadership to ensure proper understanding of documentation requirements relating to coding and billing; provides or arranges training as necessary

 EHR System Support:

• Troubleshoots and resolves issues related to Electronic Health Record (EHR) systems and workflows, ensuring no barriers to quality documentation or patient care
• Assists with the resolution of rejected claims in coordination with the billing team
• Acts as the point of contact for documentation or technical challenges with the EHR system

Reporting & Compliance:

• Prepare reports on documentation quality for leadership and regulatory bodies
• Ensures compliance with ethical coding and billing practices through internal audits and quality checks

Training & Education:

• Offers real-time support, training, and guidance to clinicians on documentation best practices
• Educates and monitors new programs and staff, providing increased auditing to ensure quality documentation standards are met

Documentation Improvement:

Team Support & Professional Development:

• Serves as a team member in Health Information Management (HIM) operations, offering insight into departmental procedures and projects
• Participates in committees and works with external consultants to ensure compliance with documentation and billing standards
• Supports personal growth by meeting development goals outlined in the Staff Development Plan

Additional Duties:

• Adapts to changing job duties as necessary based on agency needs

Qualifications

• Associate’s degree in Health Information Management (RHIT) or bachelor’s degree in relatable healthcare studies (RHIA).  Candidates without a degree may be considered (minimum of three years’ experience with behavioral health-addiction and mental health)
• Certified Professional Coder (CPC) certification or extensive behavioral health billing/coding experience highly preferred
• Identify and resolve errors and inconsistencies in medical records 
• Knowledge of pertinent and applicable federal, state, and local regulations.   
• Minimum of 3 years’ experience utilizing electronic health records (Required)
• Proficient knowledge of Microsoft Office products (Teams, PowerPoint, OneDrive)
• Read, interpret, and concisely relay formal language within contracts and accreditation standards 
• Strong organizational skills, careful attention to detail and knowledge of HIM workflow/processes and data collection
• Strong critical thinking skills and logical thinking
• Well-developed communication and interpersonal skills
• Working knowledge of ICD-10-CM, CPT, with a primary focus on E&M coding, and HCPCS coding practices and guidelines. 

Competencies

Adaptability: Adapt to change and remain open to new ideas and responsibilities  

Confidentiality: Understand and apply HIPAA laws, 42 CFR Part 2, and other regulations protecting patient privacy and rights to ensure patient information remains confidential and complies with legal standards, promoting trust and legal compliance

Conflict Management: Listen well, resolve problems, and work with difficult individuals to find solutions 

Communication: Communicate effectively, listen actively, and deliver clear presentations

Customer Service: Provide excellent customer service by working well with patients, clients, and colleagues, promoting a positive company image

Decision Making: Make thoughtful decisions after considering various options and seeking input from others

Dependability: Meet deadlines, be punctual, maintain good attendance, and work independently

Ethics: Be honest, accountable, and maintain confidentiality to build a foundation of trust and professionalism, ensuring compliance with ethical standards

Infection Control: Adhere to universal precautions and infection control standards to protect patients, staff, and visitors

Initiative: Take proactive action, seek new opportunities, and drive projects to completion

Innovation: Offer creative solutions and be open to change, taking calculated risks to help the organization stay competitive and responsive to evolving needs and challenges

Interpersonal Skills: Build strong relationships, adapt to different personalities, and solicit feedback to enhance collaboration and teamwork, ensuring positive interactions across diverse teams

Job Knowledge: Keep job knowledge current and demonstrate a deep understanding of the responsibilities and tasks

Organizational Skills: Organize information efficiently, maintain an organized workspace, and manage time effectively

Patient Rights: Adhere to patient rights standards and serve as a resource for patients regarding their rights. Empower patients, ensuring they understand and can exercise their rights, leading to higher patient satisfaction and legal compliance

Problem Solving: Identify contributing factors and resolve complex situations through research and collaboration

Product Expertise: Be knowledgeable about the organization's programs, services, and their impact on the community

Productivity: Manage workload effectively and meet productivity goals to ensure efficient use of time and resources, meeting performance expectations

Professionalism: Exhibits professional behaviors such as maintaining the CAT Code of Ethics, working cooperatively with others following CAT personnel policies

Quality: Strive for accuracy, minimize errors, and seek improvements

Reporting: Effectively report unusual incidents and variances to agency management for timely intervention or follow-up to ensure safety and accountability in the workplace, allowing for continuous improvement

Self-Development: Actively pursue opportunities for personal and professional growth

Strategic Thought: Articulate a vision, think creatively, and define solutions to challenges

Teamwork: Collaborate with others to meet shared goals, value diverse perspectives, and maintain mutual respect

ICD-10-CM, CPT, and HCPCS Coding Knowledge:

• CPT (Current Procedural Terminology): Applies understanding of coding practices related to medical procedures and services, ensuring accurate billing and reporting of healthcare services rendered
• HCPCS (Healthcare Common Procedure Coding System): Knowledge of this coding system, which is primarily used for Medicare and Medicaid services, covering procedures, equipment, and supplies not included in CPT codes
• ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification): Demonstrates working knowledge of coding for diagnoses and medical conditions in clinical settings, ensuring proper documentation and coding for patient diagnoses

Physical requirements

• May need to sit for extended periods of time