ACCOUNTABILITY OBJECTIVE:
The Documentation Specialist evaluates the medical records to ascertain the degree of documentation compliance with State and Federal regulations; and provides consultative services to the medical records staff, physicians, and other pertinent staff.
REPORTING RELATIONSHIPS:
The Documentation Specialist reports to the System Director, MPAS, Community CEO’s or MPAS designee and does not supervise anyone. This position has frequent contact with the System Compliance Department, Administrators, physicians, medical records, State and Federal agencies, various Department Heads, and nursing staff.
MAJOR ACTIVITIES:
Evaluates the quality of medical record systems in the system to determine that the service is in compliance with State and Federal regulations and medical records standards.
Reviews patient chart documentation for compliance with professional medical records standards and practices and for State and Federal regulations.
Provides consultation to physicians concerning new State and Federal regulations; advises them on the impact upon medical records services and actions required for implementation and compliance.
Consults with facility administrators and their medical records staff to provide them with interpretations of State and Federal regulations; advises them on appropriate corrective measures for compliance.
Maintains liaison with various State, Federal, and local organizations regarding the development, definition, and administration of medical records standards and practices.
Review patients' records to ascertain if appropriate type and quality of care was given according to established criteria for the diagnosis.
Performs retrospective chart review of patients who have a change of status to assure that necessary payment status is changed.
Visits system facilities and interviews administrators, nursing staff and medical records staff to obtain information regarding policies and procedures.
Reviews and evaluates policies and procedures to determine that they are in writing and meet the requirements of the various regulations.
May investigate complaints regarding medical records services and prepare reports of the findings.
Perform other related duties within the scope of the job classification.
EDUCATION, TRAINING REQUIREMENT:
Graduate from an accredited School of Nursing with current licensure in state of employment.
Possess a high degree of clinical documentation knowledge to support coding, review of medical records, and physicians.
Possess a high degree of skill in human relations with ability to deal constructively on a one-to-one basis with physicians, nursing staff, department heads, administrative personnel, health information personnel, patients, and representatives of government or third party agencies.
Appalachian Regional Healthcare (ARH), the Healthcare System of Appalachia, and ranked as one of the Top 10 Employers in Kentucky by Forbes Magazine, is a not-for-profit health system operating 13 hospitals in Barbourville, Hazard, Harlan, Hyden, Martin, McDowell, Middlesboro, Prestonsburg, South Williamson, West Liberty and Whitesburg in Kentucky; as well as Beckley and Hinton in West Virginia, as well as multi-specialty physician practices, home health agencies, home medical equipment stores and retail pharmacies. ARH employs more than 6,000 people with an annual payroll and benefits of $330 million generated into our local economies. ARH also has a network of more than 600 active and courtesy medical staff members. ARH is the largest provider of care and single largest employer in southeastern Kentucky and the third largest private employer in southern West Virginia, and is consistently recognized for its medical excellence.
