HIM Documentation Integrity Specialist
About The Position
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. Required to pay meticulous attention to detail and have proficient knowledge of the electronic health record (Epic) in order to review and validate completeness and accuracy of medical record documentation for inpatients, ambulatory surgery, emergency department, and various outpatient encounters as indicated. Incumbent must demonstrate expert level knowledge of HIM pertinent Rules and Regulations for each delivery network and have the ability to validate automated deficiencies and/or manually assign deficiencies as appropriate. Identifies discrepancies and makes any necessary corrections to dates of service, missing core elements, and/or assignments. Participates in weekly alert and notification process to support routine suspension protocols. Assist medical staff members with Epic training and questions regarding record completion work flow. EEO/AA/Disability/Veteran
Requirements
- Associates degree in healthcare related field or equivalent experience as a Documentation Integrity Technician
- Two (2) to three (3) years of health information management experience required; formalized training in medical record documentation requirements to ensure regulatory compliance.
- Requires knowledge of medical terminology and a thorough knowledge of a variety of regulations concerning the content of Medical Records.
- Thorough understanding of Documentation Integrity and MR Completion Policy.
- Working knowledge of computers for data entry and search and retrieval.
- Accurate keyboard skills ( 30-35 wpm).
- Ability to use peripheral equipment such as bar code scanners, printers, fax machine, photocopier.
- Ability to effectively communicate verbally and to deal professionally with co-workers, other departments, and medical personnel.
- Knowledge of various software packages.
Nice To Haves
- RHIA or RHIT preferred.
- RHIA or RHIT preferred.
Responsibilities
- From the Epic Analysis Needed work queue, analyzes the on line medical record for inpatient, ambulatory surgery, and/or emergency department patients as well as various outpatient encounters. Determines completeness and accuracy of information as prescribed by hospital regulations, the Joint commission on Accreditation of Health Care Organizations and appropriateness state/federal regulations initiating appropriate action to correct any deficiencies noted.
- Monitors and maintains the Epic Analysis work queue as assigned by the Senior Analysts to ensure, timely and accurate statistical reporting notification to physicians on status of incomplete medical records assigned to them for record completion.
- Ensures adherence to hospital procedure regarding timely completion of delinquent medical records as outlined in the Hospital By Laws. Follows the department guidelines for notification and suspension of physicians who fail to complete their records within the required timeline.
- Provides assistance to physicians and secretaries responding to telephone and walk-in request/inquires in a timely manner. Assists patients/customers in providing good customer service. Demonstrates acknowledgement of responsibility to practice and promote good customer relations and mutual respect 100 % of the time.
- From time to time will complete special projects as assigned by the supervisor or manager.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
