The Document Management / Coding Specialist at St. Charles Health System ensures timely and accurate documentation and coding of the Hospice medical record. This position acts as first level problem solver and subject matter expert for medical record documentation issues. This position does not directly manage other caregivers but reviews the documentation of Hospice Clinical Caregivers.
(May perform additional duties of similar complexity within SCHS as required or assigned)
Prepares and processes Plan of Treatment, Certification of Terminal Illness and Physician Orders within regulatory guidelines.
Accurate and timely coding of medical records to ensure appropriate reimbursement.
Reviews documents for completeness and accuracy prior to processing.
Effectively coaches clinical staff on documentation deficiencies.
Assures proper release of information.
Prepares GIP, Respite and Transfer packets.
Prepares and distributes medical records to long-term care facilities.
Interfaces with long-term facility billers to determine Medicaid patient liability and documents in EMR.
Acts as a resource and support for clinical staff.
Maintains tracking system to identify needed and missing orders. Follows up on orders not received within established timeframes.
Runs reports and complies data.
Assist with monitoring of the Hospice department’s quality improvement program.
Demonstrates knowledge of the Hospice regulatory requirements as they relate to coding of the medical record.
Provides effective coverage for primary office roles in the absence of assigned staff as needed.
Assist in patient related activities, as needed and appropriate, minimizing office work for clinical staff.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the health system’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.
Education: High school diploma or GED required. Associates degree in health related field preferred.
Licensure/Certification/Registration: Valid Oregon driver's license and ability to meet SCHS driving requirements. Ability to travel to business functions/trainings/meetings and all SCHS worksites required.
Coding certification preferred.
Personal Protective Equipment: Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.
Experience: One year medical records experience required. Home Health- Hospice HCS-D certification preferred.
Must have excellent communication skills and ability to interact with a diverse population and professionally represent SCHS.
Ability to effectively interact and communicate with all levels within SCHS and external customers/clients/potential employees.
Strong team working and collaborative skills.
Ability to effectively reach consensus with a diverse population with differing needs.
Ability to manage facilitation and consensus building among health care professionals and agencies and achieve expected results.
Ability to work under pressure in a fast-paced environment.
Ability to multi-task and work independently.
Attention to detail.
Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal interactions.
Strong analytical, problem solving and decision-making skills.
Excellent organizational and multi-tasking skills.