HIM Documentation Integrity Specialist

Valleywise Health System • Phoenix, AZ

4d

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 on 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 the Valleywise Health medical staff.

The position reviews patient information documented by Valleywise Health medical staff in hardcopy and electronic formats for provider and documentation deficiencies. It enters data for provider notifications and tracks incomplete health records. The Specialist coordinates workflow for relevant systems and processes, performs quality monitoring, and participates in efforts to improve EHR integrity outcomes. The role also makes charge corrections, additions, and deletions based on Epic and MedAssets edits and errors to support timely, accurate, compliant billing; identifies patterns and reports them to the HDI Supervisor; and may assist with training or mentoring other HIM Department members. The position offers 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 demonstrating the required specialized knowledge and abilities.
• Two years of progressively responsible experience in Health Information Management, Clinical Documentation Improvement, Coding, Clinical Auditing/Review related to the Revenue Cycle/Revenue Capture Assurance program, or a related healthcare field demonstrating the required skills and abilities.
• Within 24 months of employment, hold either a valid Arizona or compact-state RN or LPN license in good standing with the issuing Board of Nursing, or certification as RHIA, RHIT, CCS, CCS-P, CPC, CIC, or COC.
• Successfully complete Valleywise Health-provided training on HIPAA and applicable state and federal health-record regulations.
• Demonstrate knowledge of HIPAA privacy and security regulations through appropriate handling of protected health information, confidentiality, and discretion.
• Follow applicable federal and state regulations, Valleywise Health policies and procedures, and Corporate Compliance Plans.
• Strong knowledge of chart completion processes, HIPAA regulations, and DNV standards.
• Ability to work independently in a fast-paced environment and to learn within a short period of time.
• 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 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; and strong attention to detail.
• Ability to adapt positively to change, follow through on assignments, self-motivate, plan work activities, 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.
• Electronic Health Record experience.
• Epic system training.
• Certification as a CRCR (Certified Revenue Cycle Representative).

Responsibilities

• Monitor, measure, and report on healthcare-provider documentation to support EHR integrity.
• Compile and provide provider feedback on critical and major documentation errors that may affect document integrity or patient care.
• Request clarification from clinicians when needed.
• Serve as a liaison between Clinical Documentation Improvement Specialists and Coders and the Valleywise Health medical staff.
• Review hardcopy and electronic patient information for provider and documentation deficiencies.
• Enter data for provider notifications and track incomplete health records.
• Coordinate workflow on related systems and processes.
• Perform quality monitoring and participate in activities to improve EHR integrity outcomes.
• Make 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.
• Assist with training and/or mentoring other HIM Department members as needed.

What This Job Offers

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