Documentation Specialist

Documentation Specialist – Atrium Health

Location: 10169 Atrium Health Floyd Medical Center – Clinical Documentation Improvement

• Position Type: Full-time
• Benefits Eligible: Yes
• Hours per week: 40
• Schedule Details/Additional Information: NA
• Pay Range: $37.50 – $56.25 per hour

• Major Responsibilities:
  • Reviews Medicare inpatient medical records to ensure appropriate documentation of comorbidities and complicating diagnoses.
  • Manages daily work list of patients meeting priority list diagnoses for documentation improvement, including top volume/variance DRG pairs, Pneumonia (DRG 089, Respiratory (DRG 079), Sepsis (DRG 320, 321, and 416).
  • Queries appropriate physicians for necessary documentation and follows up to ensure query response.
  • Maintains a database of queries, responses, and documentation outcomes.
  • Uses database reports to identify physician education needs and reports on the success of the documentation program; develops and provides education programs to appropriate providers.
  • Acts as a resource to Utilization Managers for early assignment of a working DRG on all Medicare patients.
  • Provides education/training to other UM staff to maintain a backup to the documentation specialist during time off; coordinates patient care throughout inpatient or observation stays.
• Actively participates in Performance Improvement (PI) processes.
• Participates in departmental and organization-wide Lean/Six Sigma programs, maintaining workload to progress toward departmental goals and objectives.
• Identifies, documents, and reports variances, quality, cost and risk issues to management; supports review and modification of policies, procedures, and processes.
• Performs other related duties as assigned.

• Valid, active unencumbered nursing license approved by the Georgia Licensing Board; HIM/Coding certification preferred.

• Graduate of an accredited School of Professional Nursing, BSN or MSN preferred.

• Five or more years of hospital experience caring for short‑term acute patients with comprehensive understanding of reimbursement mechanisms.

• Full range of body motion including handling and lifting patients, manual and finger dexterity, and eye‑hand coordination.
• Standing and walking for extensive periods of time; occasionally lifts and carries weight up to 50 pounds.
• Ability to distinguish letters, numbers, and symbols with vision and hearing within normal range to respond to code alerts and equipment alarms.
• Work‑related stress due to volume and time constraints with irregular working hours.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

Advocate Health offers a comprehensive suite of Total Rewards, including compensation, benefits, and programs to invest in your career development and well‑being.

• Base compensation listed within the pay range based on qualifications, skills, relevant experience, and/or training.
• Premium pay such as shift, on‑call, and more based on job.
• Incentive pay for select positions.
• Opportunity for annual increases based on performance.

• Paid Time Off programs.
• Health and welfare benefits such as medical, dental, vision, life, and short‑ and long‑term disability.
• Flexible Spending Accounts for eligible health care and dependent care expenses.
• Family benefits such as adoption assistance and paid parental leave.
• Defined contribution retirement plans with employer match and other financial wellness programs.
• Educational Assistance Program.

Advocate Health is the third‑largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. It operates under the names Advocate Health Care in Illinois;
Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin. The organization serves nearly 6 million patients, engages in hundreds of clinical trials and research studies, and maintains a large graduate medical education program. It is nationally recognized for expertise in cardiology, neuroscience, oncology, pediatrics and specialized musculoskeletal programs, among others.

Mid‑Senior level

Full‑time

Administrative

Hospitals and Health Care

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