Documentation Specialist

Reviews Medicare inpatient medical records to ensure appropriate documentation of co-morbidities and complicating diagnoses. Manages daily work list of patients meeting priority list diagnoses for documentation improvement. Queries appropriate physician for necessary documentation. Maintains database on queries, response to query and documentation outcomes. Uses database reports to identify physician education needs and to report on success of documentation program. Acts as a resource to the Utilization Managers for early assignment of a working DRG on all Medicare patients. Provides education/training to other UM staff. Coordinates patient care throughout inpatient or observation stays. Actively participates in Performance Improvement (PI) processes and Lean/Six Sigma program. Identifies, documents and reports variances, quality, cost and risk issues to management.