[Hiring] Health Information Management Documentation Integrity Specialist @Yale New Haven Health

Role Description

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
• Various outpatient encounters

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. Assists medical staff members with Epic training and questions regarding record completion workflow.

Responsibilities

• From the Epic Analysis Needed work queue, analyzes the online medical record for inpatient, ambulatory surgery, and/or emergency department patients as well as various outpatient encounters.
• 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.
• Provides assistance to physicians and secretaries responding to telephone and walk-in requests/inquiries in a timely manner.
• From time to time will complete special projects as assigned by the supervisor or manager.

Qualifications

• Associates degree in healthcare related field or equivalent experience as a Documentation Integrity Technician; RHIA or RHIT preferred.
• Two (2) to three (3) years of health information management experience required; formalized training in medical record documentation requirements to ensure regulatory compliance.
• RHIA or RHIT preferred.
• 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.

Company Description