HIM Documentation Integrity Specialist I -Tue-Sat 8a-430p
Facility: Valleywise Health Medical Center
Department: Health Information Management
Schedule: Regular FT 40 Hours Per Week
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 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 by Valleywise Health medical staff (hardcopy and electronic) for provider/documentation deficiencies and complete 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 work flow 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.
- Requires an Associate's 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 or Health Information Administration or related field is preferred.
- Must have 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.
- Formal Auditing/CDI/Coding/Revenue Cycle training is preferred.
- Epic system training is preferred.
- 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 & Abilities:
- Must be able to perform all functions required of the HIM Documentation Integrity Specialist I.
- 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 all Valleywise 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 ability to learn within a short period.
- Must have strong understanding of medical terminology, anatomy and physiology, as well as 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 have the ability to categorize data both 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 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 and Valleywise Health operational and fiscal goals.
- Requires the ability to read, write and communicate effectively in English.