HIM Documentation Integrity Specialist
About The Position
Under the direction of the Healthcare Documentation Integrity (HDI) Supervisor, the HIM Documentation Integrity Specialist helps ensure the integrity of the Electronic Health Record (EHR) by monitoring, measuring, and reporting on healthcare provider documentation. The Specialist provides feedback to providers about critical and major errors that could affect document integrity or patient care, and may request clarification from clinicians. The role supports a quality assurance program and serves as a liaison between Clinical Documentation Improvement Specialists and Coders and Valleywise Health medical staff. The position reviews and analyzes patient information documented by medical staff in hardcopy and electronic formats for provider and documentation deficiencies. It also enters data for provider notifications and tracks incomplete health records. The Specialist coordinates workflow involving systems and processes, performs quality monitoring, and participates in activities to improve EHR integrity. The role corrects, adds, or deletes charges based on Epic and MedAssets edits and errors to help ensure accurate and compliant billing, identifies patterns, and shares feedback with the HDI Supervisor. The Specialist may assist with training or mentoring other HIM Department members and has opportunities for professional growth and development. Hourly pay range: $21.34–$31.48.
Requirements
- Associate degree in nursing, health information technology, or a related field, or an equivalent combination of training and progressively responsible experience that provides the required knowledge and abilities.
- Two years of progressively responsible experience in Health Information Management, Clinical Documentation Improvement, Coding, Clinical Auditing/Review related to Revenue Cycle/Revenue Capture Assurance, or a related healthcare field demonstrating the required skills and abilities.
- Within 24 months of employment, possess either a valid Arizona or compact-state RN or LPN license in good standing with the issuing Board of Nursing, or a RHIA, RHIT, CCS, CCS-P, CPC, CIC, or COC certification.
- Successfully complete Valleywise Health-provided training on HIPAA and applicable state and federal health-record regulations.
- Knowledge of HIPAA privacy and security regulations and appropriate handling of protected health information, confidentiality, and discretion.
- Ability to follow federal and state regulations, Valleywise Health policies and procedures, and Corporate Compliance Plans.
- Strong knowledge of the chart completion process, HIPAA regulations, and DNV standards.
- Ability to work independently in a fast-paced environment, learn quickly, and work independently or as part of a team.
- Strong understanding of medical terminology, anatomy, physiology, and disease processes.
- Excellent research skills and ability to maintain the highest level of confidentiality.
- Proficiency with Microsoft Office software, including Word, Excel, and Outlook.
- Ability to categorize data in electronic and hardcopy formats.
- Good interpersonal communication and customer service skills, verbally and in writing, including basic grammar, spelling, and punctuation.
- Ability to collaborate with others to understand the scope of data integrity capabilities within the EHR.
- Excellent organizational and team-building skills; quality-conscious and customer-oriented.
- Strong attention to detail; ability to adapt positively to change and follow through on assignments.
- Self-motivation and ability to plan work activities and set priorities aligned with departmental and Valleywise Health 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.
- Electronic Health Record experience.
- Epic system training.
- CRCR (Certified Revenue Cycle Representative) certification.
Responsibilities
- Monitor, measure, and report on healthcare provider documentation to help ensure EHR integrity.
- Compile and provide feedback to providers on critical and major errors that may affect documentation integrity or patient care.
- Request clarification from clinicians when necessary.
- Serve as a liaison for Clinical Documentation Improvement Specialists and Coders to 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.
- Coordinate workflow involving 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 and compliant billing.
- Identify patterns and provide feedback to the HDI Supervisor.
- Assist with training and/or mentoring other HIM Department members as necessary.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
