Documentation Specialist jobs in Baton Rouge, LA

JOB PURPOSE OR MISSION: Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes including but not limited to HACs, PSIs, and quality measures. Educates all members of the patient care team on an ongoing basis. Performs duties for the age population served, as defined in the department’s scope of service.

PERFORMANCE CRITERIA

CRITERIA A: Everyday Excellence Values - Employee demonstrates Everyday Excellence values in the day-to-day performance of their job.

PERFORMANCE STANDARDS: • Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community. • Takes initiative in living our Everyday Excellence values and vital signs. • Takes initiative in identifying customer needs before the customer asks. • Participates in teamwork willingly and with enthusiasm. • Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care. • Keeps customers informed, answers customer questions and anticipates information needs of customers.

CRITERIA B: Corporate Compliance - Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines, and the GHS Corporate Compliance Guidelines.

PERFORMANCE STANDARDS • Practices diligence in fulfilling the regulatory and legal requirements of the position and department. • Maintains accurate and reliable patient/organizational records. • Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts. CRITERIA C: Personal Achievement - Employee demonstrates initiative in achieving work goals and meeting personal objectives.

PERFORMANCE STANDARDS • Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high. • Adheres to high moral principles of honesty, loyalty, sincerity, and fairness. • Upholds the ethical standards of the organization.

CRITERIA D: Performance Improvement - Employee actively participates in Performance Improvement activities and incorporates quality improvement standards in his/her job performance.

PERFORMANCE STANDARDS • Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations. • Initiates or redesigns to continuously improve work processes. • Contributes ideas and suggestions to improve approaches to work processes. • Willingly participates in organization and/or department quality initiatives.

CRITERIA E: Cost Management - Employee demonstrates effective cost management practices.

PERFORMANCE STANDARDS • Effectively manages time and resources • Makes a conscious effort to effectively utilize the resources of the organization — material, human, and financial. • Consistently looks for and uses resource saving processes.

CRITERIA F: Patient & Employee Safety - Employee actively participates in and demonstrates effective patient and employee safety practices.

PERFORMANCE STANDARDS • Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety. • Employee proactively reports errors, potential errors, injuries or potential injuries. • Employee demonstrates departmental specific patient and employee safety standards at all times. • Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures and plans.

JOB FUNCTIONS

ESSENTIAL JOB FUNCTIONS include, but are not limited to:

1. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Health Information Management coding staff to ensure the clinical documentation reflects the level of service rendered to patients and is complete and accurate.

PERFORMANCE STANDARDS: • Possesses and maintains extensive knowledge of DRG payor regulations, documentation opportunities, clinical documentation requirements, and coding guidelines. • Identifies documentation needs and facilitates modifications to clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record and appropriate reimbursement is received for all patients with a DRG based payor. • Completes Admission Reviews by reviewing charts and identifying the most appropriate principle diagnosis, CC’s, and procedurese, to accurately reflect severity of illness in compliance with regulations. • Confers with coding specialists and manager concurrently to ensure appropriate DRG and completeness of supporting documentation. • Confers with physicians face-to-face and/or via documentation clarification form, to obtain documentation, and educate physicians/staff for appropriate DRG to reflect the severity of illness. • Reviews clinical issues with coding staff to assign a working DRG. • Addresses conflicting or incomplete documentation issues by reviewing medical records and following up with physician as appropriate, within agreed upon timelines. Reviews chart further with Manager as appropriate. • Performs admission/continued stay reviews using appropriate guidelines. • Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes including but not limited to HACs, PSIs, and Quality Measures • Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart and updates worksheets at least every 48 hours or as indicated. • Processes discharges by updating the DRG Worksheet to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnoses.

2. Functions as internal resource for all clinical documentation issues.

PERFORMANCE STANDARDS: • Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. • Refers patient cases to the Care Management, Social Services and/or other departments for continued Utilization Management, discharge planning or social work services as appropriate. • Documents, analyzes and reports instances of inappropriate patient care, discharge delays, etc. to Manager. • Identifies, monitors and evaluates quality issues related to clinical practice in conjunction with medical staff leadership. • Serves on all applicable committees or teams relating to clinical documentation issues as assigned.

3. Performs all other duties as assigned.

EXPERIENCE REQUIREMENTS Four years recent acute care clinical experience. Utilization Review or coding experience preferred.

EDUCATIONAL REQUIREMENTS BSN preferred.

SPECIAL SKILL, LICENSE AND KNOWLEDGE REQUIREMENTS Current Louisiana RN licensure

Strong critical thinking skills and exceptional ability to integrate knowledge. Excellent observation, communication and decision making abilities. Ability to assess, evaluate, and teach all members of the care team. Ability to strongly communicate and interact with all levels of professions, including but not limited to physicians and nursing personnel, managers, various support staff departments, and physician offices, in a non-confrontational and professional manner.

HIPAA REQUIREMENTS: Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job / Position including but not limited to: Medical records w/out limitation both paper and electronic, patient demographics, patient information related to surgery or appointment schedules, information related to patient location, religious beliefs, lab or radiology results, medical records related to quality/data, patient financial and/or 3rd party billing, patient complaints, research information, investigatory information.

SAFETY REQUIREMENTS: Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, PPE, exposure control plans, hand washing, environment of care.

Full-Time