HIM Documentation Integrity Specialist II

Valleywise Health; Phoenix (AZ); On-site; USD 34,000 - 51,000; Full time

Job summary

Valleywise Health seeks an HIM Documentation Integrity Specialist II to ensure EHR documentation accuracy. You will monitor clinical notes, identify critical errors, and provide actionable feedback to clinicians to improve patient data quality and billing integrity.

The role supports CDI specialists and coders, coordinating workflow and participating in quality assurance activities. Experience with Epic and EHR systems is essential.

Qualifications

• Requires an associate degree in nursing or health information technology, or equivalent experience.
• A bachelor’s degree in nursing, health information administration, or related field preferred.
• Minimum of 3 years in CDI/Coding/Auditing related to Revenue Cycle is required.
• Electronic Health Record experience is required.
• Epic system training is preferred.

Responsibilities

• Monitor and report on documentation integrity within the EHR.
• Review clinician notes for content and context and identify major errors.
• Provide feedback to clinicians to reduce recurring errors and improve data quality.
• Coordinate workflow and communicate with CDI specialists and Coders.
• Assist with training and mentoring other HIM staff as needed.
• Support quality monitoring and data entry for provider notifications and tracking.

Skills

HIPAA knowledge

PHI handling

Data integrity

Attention to detail

Communication skills

MS Office

Chart completion

Education

Associate degree in nursing or health information technology

Bachelor’s degree preferred

Tools

Epic

MedAssets

Job description

HIM Documentation Integrity Specialist II Internal Job

Under the direction of the Healthcare Documentation Integrity (HDI) Supervisor, this position ensures the integrity of the Electronic Health Record (EHR) by monitoring, measuring, and reporting on documentation created by healthcare providers. Reviews documentation created within the EHR for content and context. The Senior 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 the 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 other HIM Department members. 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 ensure expedited, accurate, and compliant billing. Identify patterns and provide feedback to the HDI Supervisor.

Hourly Pay Range: $24.96 - $36.82

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:

• Must have a minimum of three (3) 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 is required.
• Experience in providing classroom and/or on-site training is preferred.

Specialized Training:

• Formal Auditing/CDI/Coding/Revenue Cycle training is preferred.
• Epic system training is preferred.

Certification/Licensure:

• Must possess either 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/CPC-H/CIC/COC.
• Certification as a CRCR (Certified Revenue Cycle Representative) is preferred.
• Certification as a CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) is preferred.

Knowledge, Skills, and Abilities:

• Must be able to perform all HIM Documentation Integrity Specialist I functions.
• 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, as well as allValleywise Health policies, procedures, and Corporate Compliance Plan.
• 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 the ability to learn within a short period.
• 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.

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