DOCUMENTATION SPECIALIST-SOC SERVICE in CANTON, Ohio at Aultman Health Foundation

Aultman Hospital

The Aultman Registered Nurse (RN) is a professional nurse that provides indirect, primary nursing care to patients. The RN delegates and coordinates patient care, based upon a documented assessment of the patient’s needs. The RN supervises the care provided by individuals such as licensed practical nurses, patient care technicians/state tested nursing assistants/nurse aides, medical assistants, and etc., if applicable.

The purpose of the Documentation Specialist is to evaluate overall completeness and quality of clinical documentation. The Documentation Specialist works in partnership with physicians, residents, case managers, nurses and coding professionals to ensure medical records accurately reflect patient acuity primarily for quality reporting and DRG assignment.

• Current registered nurse (RN) licensed in the state of Ohio.

• Graduate of an approved School of Nursing: BSN.

• Minimum 2 years acute care clinical experience required.

• Critical Care or Cardiac experience preferred.

• Knowledge and understanding of coding principals helpful.

• Proficient computer skills to complete tasks as required.

• Must be organized, able to effectively prioritize tasks and exhibit appropriate time management skills.

• Must be detail oriented while focusing on safe practices and quality care.

• Demonstrates effective communication.

• Effective appropriate and professional interactions with colleagues/physicians, patients and visitors.

• Ability to manage multiple demands from a variety of constituents

• Able to effectively analyze data and present meaningful results to Medical Staff, Finance and Clinical Division

• Able to work with all departments/ personnel in a cross functional environment

• Refined negotiating skills and the ability to deal with problem solving and conflict resolution

• Computer skills helpful, {Microsoft products, Cerner EMR)

• Completes initial review or patient records within 24-48 hours of admission/ CDS assignment for selected admissions covering all financial types. Performs concurrent review process to promote documentation that accurately reflects the severity of patient's illness and complies with coding and documentation guidelines.

• Evaluates documentation and obtains additional documentation as needed to support assignment of the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality and severity of illness.

• Conducts follow up record reviews of patients every 2-3 days after initial review.

• Develops and maintains documentation query protocol and educates staff on processes as needed.

• Queries physicians regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.

• Initiates assertive yet tactful communication with physician or other care provider when documentation is unclear, using the most appropriate communication method. Documentation Query Note in the EHR, face to face contact, email and or phone calls.

• Consults Assistant Manager of Clinical Documentation as needed to obtain direction, clarification and support in order to promote complete and accurate clinical documentation.

• Tracks responses and trends compliance with physician queries.

• Educates physicians, residents and key healthcare providers regarding clinical documentation in the health record.

• Identifies trends in clinical documentation and /or potential problems and develops action plans as needed.

• Partners with coding professionals to ensure accurate and complete documentation in the health record to determine a final DRG, severity of illness, risk of mortality.

• Serves as a resource person for coding professionals to assist with clinical questions.

• Reads and reviews coding guidelines, Medicare updates, professional journals, etc. to maintain an up-to-date working knowledge of coding and reimbursement principals.

• Contacts Medical Staff, Assistant Manager of Clinical Documentation, and/or coders to expedite queries and facilitate final billing.

• Assist in other Clinical Documentation improvement projects as needed.

• Other duties as assigned.

• Meal and break times are coordinated with other staff members to maintain adequate coverage.

• Shifts are scheduled or changed due to the staffing needs of the unit/department based upon volume and acuity.

• Work weekends and holidays as assigned or as applicable based on department needs.

• Cross training depending upon department needs.

• Hybrid position - Potential for working from home and on-site.

• Flexible day shift Monday - Friday or hours required by the job, potential for off-shift and/or weekend hours.

• Subject to frequent interruptions and changes in priorities of duties throughout the day.

Category I - Includes tasks that involve exposure to blood, body fluids, or tissues. All procedures or other job-related tasks that involve an inherent potential for spills or splashes of, or mucous membrane or skin contact with blood, body fluids or tissues are Category I tasks. Use of appropriate protective measures is required for every employee engaged in Category I tasks.

Demands

Frequency

Remarks

Lifting 0-10 lbs

Never

Lifting 10-20 lbs

Never

Lifting 20-35 lbs

Never

Lifting 35-50 lbs

Never

Lifting 50-75 lbs

Never

Lifting 75-100 lbs

Never

Lifting over 100 lbs

Never

Forward Reaching

Never

Overhead Reaching

Never

Standing

Occasional 10-33%

Walking

Occasional 10-33%

Sitting

Continuous 66% of the day

Climbing

Never

Stairs/Ladder

Never

Bending/Stooping

Never

Twisting/Turning

Occasional 10-33%

Kneeling/Squatting

Never

Crawling

Never

Pushing/Pulling 0-10 lbs

Never

Pushing/Pulling 10-20 lbs

Never

Pushing/Pulling 20-35 lbs

Never

Pushing/Pulling 35-50 lbs

Never

Pushing/Pulling 50-100 lbs

Never

Pushing/Pulling over 100 lbs

Never

Carrying 0-10 lbs

Never

Carrying 10-20 lbs

Never

Carrying 20-35 lbs

Never

Carrying 35-50 lbs

Never

Carrying 50-100 lbs

Never

Carrying over 100 lbs

Never

Grasping/repetitive sustained

Occasional 10-33%

Fine motor coordination

Continuous 66% of the day

Vision: Near/Far/Color

Continuous 66% of the day

Hearing: ordinary conversation/other

Continuous 66% of the day

Sitting

Continuous 66% of the day

Climbing

Never

Stairs/Ladder

Never

Twisting/Turning

Occasional 10-33%

Kneeling/Squatting

Never

Pushing/Pulling 50-100 lbs

Never

Pushing/Pulling over 100 lbs

Never

Carrying 35-50 lbs

Never

Carrying 50-100 lbs

Never

Fine motor coordination

Continuous 66% of the day

Vision: Near/Far/Color

Continuous 66% of the day

Hearing: ordinary conversation/other

Continuous 66% of the day

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status. The organization is an EEO/AA Employer M/F/Disability/Vet.

The organization will provide reasonable accommodations to employees or applicants with disabilities, as defined by the Americans with Disabilities Act, who are otherwise qualified to safely perform the essential functions of the job, with or without accommodation, unless such accommodation would constitute an undue hardship on the organization or poses a direct threat to the health and safety of the individual or others that cannot be sufficiently mitigated by reasonable accommodation. Any applicant or employee who requires an accommodation to perform the essential functions of his or her job or to enjoy equal benefits and privileges of employment should notify the Aultman Human Resource Department and request such an accommodation.