HIM Documentation Integrity Specialist II

Valleywise Health System • Phoenix, AZ

4d

About The Position

Under the direction of the Healthcare Documentation Integrity (HDI) Supervisor, the HIM Documentation Integrity Specialist II ensures the integrity of the Electronic Health Record (EHR) by monitoring, measuring, and reporting on healthcare provider documentation. The role reviews EHR documentation for content and context and compiles feedback for providers about critical and major errors that could affect document integrity or patient care. The auditor may request clarification from clinicians. The position supports a quality assurance program and serves as a liaison between Clinical Documentation Improvement Specialists and Coders and Valleywise Health medical staff.

The specialist conducts quality review and analysis of patient information documented by medical staff, in hardcopy and electronic formats, identifies provider and documentation deficiencies, and enters data for provider notifications and tracking incomplete health records. The role may assist with training or mentoring HIM Department members, coordinate workflow across systems and processes, conduct quality monitoring, and participate in activities to improve EHR integrity outcomes. It also performs charge corrections, additions, and deletions based on Epic and MedAssets Edits and Errors to support expedited, accurate, compliant billing, and identifies patterns for feedback to the HDI Supervisor.

Hourly pay range: $24.96–$36.82.

Requirements

• Associate degree in nursing, health information technology, or a related field, or an equivalent combination of training and progressively responsible experience providing the required specialized knowledge and abilities.
• At least three years of progressively responsible experience in Clinical Documentation Improvement, Coding, or Clinical Auditing/Review related to Revenue Cycle/Revenue Capture Assurance programs.
• Electronic Health Record experience.
• A valid Arizona or compact-state RN or LPN license in good standing with the issuing Board of Nursing, or certification as an RHIA, RHIT, CCS, CCS-P, CPC, CPC-H, CIC, or COC.
• Ability to perform all HIM Documentation Integrity Specialist I functions.
• Knowledge of HIPAA privacy and security regulations and appropriate handling of protected health information, confidentiality, and discretion.
• Ability to follow federal and state regulations and Valleywise Health policies, procedures, and Corporate Compliance Plan.
• Strong knowledge of chart completion processes, HIPAA regulations, and DNV standards.
• Ability to work independently in a fast-paced environment and learn within a short period.
• Strong understanding of medical terminology, anatomy, physiology, and disease processes.
• Excellent research skills and ability to maintain confidentiality.
• Proficiency in Microsoft Office software, including Word, Excel, and Outlook.
• Ability to categorize data in electronic and hardcopy formats.
• Strong verbal and written interpersonal communication and customer service skills, including basic grammar, spelling, and punctuation.
• Ability to work with others to understand the scope of data integrity capabilities within the EHR.
• Ability to work independently or as part of a team; excellent organizational and team-building skills.
• Quality-conscious and customer-oriented approach, with strong attention to detail.
• Ability to adapt positively to change and follow through on assignments.
• Self-motivation and ability to plan work and set priorities aligned with departmental and organizational operational and fiscal goals.
• Ability to read, write, and communicate effectively in English.

Nice To Haves

• Bachelor’s degree in nursing, health information administration, or a related field.
• Experience providing classroom and/or on-site training.
• Formal Auditing, CDI, Coding, or Revenue Cycle training.
• Epic system training.
• CRCR (Certified Revenue Cycle Representative) certification.
• CCDS (Certified Clinical Documentation Specialist) or CDIP (Documentation Improvement Practitioner) certification.

Responsibilities

• Monitor, measure, and report on healthcare provider documentation in the EHR.
• Review documentation for content and context and compile provider feedback on critical and major errors that may affect document integrity or patient care.
• Request clarification from clinicians when necessary.
• Serve as a liaison between Clinical Documentation Improvement Specialists and Coders and Valleywise Health medical staff.
• Review and analyze hardcopy and electronic patient information for provider and documentation deficiencies.
• Enter data for provider notifications and track incomplete health records.
• Assist with training and/or mentoring HIM Department members as necessary.
• Coordinate workflow on systems and processes.
• Perform quality monitoring and participate in activities to improve EHR integrity outcomes.
• Perform charge corrections, additions, and deletions based on Epic and MedAssets Edits and Errors to support accurate, compliant billing.
• Identify patterns and provide feedback to the HDI Supervisor.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree