Charge & Documentation Specialist - Health Information Management * Days - 40hrs/wk.
Requisition #: req125
FTE status: 1
The Charge and Documentation Specialist, under the direction of the HIM Director, is responsible to accurately and completely capture charges for hospital services provided by reviewing clinical documentation. This data is utilized for revenue processing, internal and external reporting, research and regulatory compliance as documented in the CPT-4 guidelines.
- CPC or other professional HIM coding certificate.
- RHIT, RHIA or CCS preferred.
- Effective communication and listening skills
- Must be fluent in English.
Essential Functions and Responsibilities:
- Enter and/or validate hospital department charges within the required timeframe to ensure accurate and timely data entry of the service codes, as appropriate.
- Ensure supporting documentation is provided for all hospital services.
- Code all diagnoses, treatments, and procedures by translating physician and nursing documentation according to the appropriate classification system for the category of patient encounter, as needed.
- Monitor payer guidelines for applicable changes, providing education to direct care providers as needed.
- Assist physicians and other direct patient care professionals with documentation questions to ensure alignment with organizational and payer guidelines.
- Maintain and update the service line charge master and other specific related changes. Routinely review charge master codes, following required internal process for additions and revisions, as needed.
- Act as a liaison between HIM, clinical areas and both the hospital and professional billing departments.
- Provide support in response to payer denials.
- Foster respect for patient privacy by maintaining confidentiality in all phases of the work.
- Participate in departmental quality activities.
- Perform other duties as assigned.
Category: Admin & Clerical, Health Care