DOCUMENTATION SPECIALIST-SOC SERVICE

Legal Entity
Aultman Hospital

Position Summary
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
urse aides, medical assistants, and etc., if applicable.

Department Summary
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.

Qualifications

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

Graduate of an approved School of Nursing: BSN.

Department Qualifications

Minimum 2 years acute care clinical experience required.

Critical Care or Cardiac experience preferred.

Knowledge and understanding of coding principals helpful.

Skills

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.

Department Skills

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, including Microsoft products, Cerner EMR.

Responsibilities & Expectations

Completes initial review of patient records within 24-48 hours of admission/CDS assignment for selected admissions covering all financial types, performing concurrent review to promote documentation that accurately reflects severity and complies with 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 or phone calls).

Consults Assistant Manager of Clinical Documentation as needed for direction, clarification and support 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 to determine a final DRG, severity of illness, risk of mortality.

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

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

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

Assists in other Clinical Documentation improvement projects as needed.

Other duties as assigned.

Working Conditions

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

Shifts are scheduled or changed due to staffing needs 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.

Hazardous Exposure Category
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.

Physical Addendum

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

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.

#J-18808-Ljbffr