Documentation Improvement Specialist

About This Role

This role involves improving medical record documentation through concurrent and retrospective interventions, interactions, and education for physicians and other licensed practitioners. The specialist will identify opportunities for documentation improvement and ensure thorough follow-through on all recommendations.

Responsibilities

• Facilitate improvement of medical record documentation by concurrent and retrospective interventions and interactions with physicians, residents, and other licensed independent practitioners
• Provide education to physicians, residents, and other licensed independent practitioners on documentation improvement
• Develop processes to identify opportunities for documentation improvement
• Intervene with attending physicians, residents, and physician extenders to facilitate documentation improvement
• Provide routine in-services to assigned clinical areas/Service Lines regarding regulatory documentation requirements including feedback on the impact of clinician documentation on Service Line metrics
• Initiate and maintain records and databases to quantify deficits, interventions, and their impact
• Conduct successful interventions related to documentation improvement and ensure follow through with all recommendations
• Identify, investigate, and evaluate practices and processes to facilitate continuous improvement in complete and accurate medical record documentation

Requirements

• Bachelor's degree
• Registered Nurse, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant or trained Physician background
• 5 years of recent hospital experience and/or verifiable Documentation Improvement experience
• Experience in an Electronic Medical Record (EMR) environment

Qualifications

• Bachelor's degree
• 5 years of recent hospital experience and/or verifiable Documentation Improvement experience

Nice to Have

• Registered Nurse with 2 years of CDI experience
• Bachelor’s Degree in Nursing
• Current Registered Nurse, Nurse Practitioner or Physician Assistant license

Skills

* Required skills