HIM Documentation Integrity Specialist

Valleywise Health; Phoenix (AZ); On-site; USD 29,000 - 43,000; Full time

Job summary

Valleywise Health is seeking a Healthcare Documentation Integrity Specialist to ensure the integrity of the EHR by monitoring, measuring, and reporting on clinician documentation. You will compile and relay feedback on errors to prevent recurrence and support quality assurance across the HIM team.

The role involves coordinating with HDI Supervisors, Coders, and Clinical Documentation Improvement Specialists, performing QA reviews, and assisting with training.

Qualifications

• Requires an associate degree in nursing or health information technology or related field, or equivalent training and experience.
• A bachelor’s degree in nursing, health information administration, or related field is preferred.
• Two (2) years of progressively responsible experience in Health Information Management, Clinical Documentation Improvement, Coding, or Clinical Auditing/Review related to Revenue Cycle.

Responsibilities

• Ensure integrity of the Electronic Health Record by monitoring, measuring, and reporting on documentation created by healthcare providers.
• Compile feedback for healthcare providers on critical and major errors to prevent recurrence and support quality assurance.
• Coordinate workflow and liaise with Clinical Documentation Improvement Specialists and Coders.
• Perform quality reviews of patient information and data entry for provider notifications and tracking of incomplete health records.
• Assist with training/mentoring within the HIM Department as needed.
• Identify patterns and provide feedback to improve EHR documentation integrity.

Skills

HIPAA privacy compliance

strong communication

data analysis

Microsoft Office

independent working

Education

Associate degree in nursing or health information technology

Bachelor’s degree in nursing or health information administration

RHIA/RHIT/CCS/CCS-P/CPC/CIC/COC certification

Tools

Epic

MedAssets Edits and Errors

Job description

Under the direction of the Healthcare Documentation Integrity (HDI) Supervisor, this position offers a unique opportunity to ensure the integrity of the Electronic Health Record (EHR) by monitoring, measuring, and reporting on documentation created by healthcare providers. The Specialist compiles feedback for healthcare providers on critical and major errors that have the potential to impact document integrity and/or patient care, thereby eliminating repetition of errors. The auditor may request clarification from the clinician. This role supports a quality assurance program, by acting as a liaison for the Clinical Documentation Improvement Specialists and Coders to the Valleywise Health medical staff. This position performs quality review and analysis of patient information documented byValleywise Healthmedical staff (hardcopy and electronic) for provider/documentation deficiencies and completes the required data entry for provider notifications and tracking of incomplete health records. As necessary, may assist with training and/or mentoring of other members of the HIM Department. Coordinates workflow on the systems and processes. Performs quality monitoring and participates in activities to improve outcomes for the integrity of the EHR. Performs charge corrections, additions and deletions based on the Epic and MedAssets Edits and Errors to assure expedite accurate and compliant billing. Identify patterns and provide feedback to the HDI Supervisor. This role also provides ample opportunities for professional growth and development.

Hourly Pay Range: $21.34 - $31.48

Qualifications

Education:

• Requires an associate degree in nursing or health information technology or related field, or an equivalent combination of training and progressively responsible experience that will result in the required specialized knowledge and abilities to perform the assigned work.
• A bachelor’s degree in nursing, health information administration, or a related field is preferred.

Experience:

• Requires two (2) years of progressively responsible experience in Health Information Management, Clinical Documentation Improvement, Coding, or Clinical Auditing/Review related to the Revenue Cycle/Revenue Capture Assurance program or related healthcare field that demonstrates an understanding of the required skills and abilities.
• Electronic Health Record experience is preferred.

Specialized Training:

• Must successfully completeValleywise Healthprovided HIPAA, state, and federal regulations as it pertains to health records required.
• Epic system training is preferred.

Certification/Licensure:

• Within 24 months of employment, must possess one of the following:a valid AZ or compact state RN or LPN license and must be in good standing with the issuing Board of Nursing; or must possess a certification as a RHIA/RHIT/CCS/CCS-P/CPC/CIC/COC.
• Certification as a CRCR (Certified Revenue Cycle Representative) is preferred.

Knowledge, Skills, and Abilities:

• Must be able to demonstrate knowledge of HIPAA privacy and security regulations as evidenced by appropriate handling of protected health information (PHI), promoting confidentiality, and using discretion when handling patient information.
• Must be able to follow all federal and state regulations and all Valleywise Healthpolicies, procedures, and Corporate Compliance Plans.
• Requires strong knowledge of chart completion process, HIPAA regulations and DNV standards.
• Requires the ability to work well independently in a fast-paced environment.
• Must demonstrate ability to learn within a short period of time.
• Must have a strong understanding of medical terminology, anatomy, physiology, and disease processes.
• Excellent research skills are required. Must be able to maintain the highest level of confidentiality.
• Must be proficient in Microsoft Office software (i.e., Word, Excel, and Outlook).
• Must be able to categorize data in an electronic and hard copy format.
• Must possess good interpersonal communication and strong customer service skills both verbally and in writing, including knowledge of basic grammar, spelling, and punctuation.
• Must be able to work with others to fully understand the scope of data integrity capabilities within the EHR.
• Requires the ability to work independently or as part of a team.
• Requires excellent organizational and team-building skills.
• Must be quality-conscious and customer-oriented.
• Strong attention to detail is required.
• Must be able to influence and adjust positively to change and follow through on all assignments.
• Must be self-motivated and able to plan work activities and set effective priorities that are aligned with departmental andValleywise Healthoperational and fiscal goals.
• Requires the ability to read, write, and communicate effectively in English.