Senior Documentation Specialist

Summary

Position Summary

Review/Audit practice medical records and coding of practice providers, to ensure proper coding completed and to ensure compliance with regulatory agencies. Assign ICD-10, CPT, or HCPCS codes to accurately capture clinical data elements according to regulatory guidelines and hospital rules and regulations. Abstracts other data elements as required. Assist with coding inpatient, ambulatory, surgery, observation encounters. Assist with educating coding staff, providers and management, setting standard of coding quality, and provide educational tools and sessions.

Develop and maintains coding guidelines in accordance with Official Coding Guidelines, disseminate and educate others on documentation requirements. Provide coder education on current best practices, changes, issues. Provide Clinician coding and documentation orientation and semi annual reviews. Share information and seeks ways to add value both to the customer and to the team. Assist and mentor non-certified and or junior coders. Partner with administration on compliance related projects that documentation.

Education

Degree/Diploma: Associates

Discipline

Health Information Administration

Required/Preferred: Preferred

Experience

Years of Experience: 5-7 years

Required/Preferred: Required

Type of Experience: Coding, Healthcare Accounting

Additional Experience Information: Physician Practice experience