[Hiring] Health Information Management Documentation 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, 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.

Responsibilities

• Analyze the online medical record for inpatient, ambulatory surgery, and/or emergency department patients as well as various outpatient encounters.
• Determine completeness and accuracy of information as prescribed by hospital regulations, the Joint Commission on Accreditation of Health Care Organizations, and appropriate state/federal regulations.
• Highlight the assigned discharge in the Analysis needed work queue and review the Deficiency Completion activity for the discharge.
• Click the Def Detective to review the summary of the patient's hospital stay and add or modify deficiencies.
• Attach messages for deficiencies needing edits by the attending for missing information.
• Refer to hospital and department procedures and policies when assigning deficiencies to physicians.
• Monitor and maintain the Epic Analysis work queue for timely and accurate statistical reporting.
• Review deficiencies in the Declined work queue and make decisions based on Epic documentation.
• Verify documentation in the Done work queue and send back incomplete documents.
• Ensure adherence to hospital procedure regarding timely completion of delinquent medical records.
• Review each deficiency on the physician's Alert Letter of Delinquent Medical records.
• Follow up daily with physician compliance regarding delinquent deficiencies.
• Generate Suspension of Admitting Privileges and Temporary Withdrawal of Clinical Privileges letters as needed.
• Provide assistance to physicians and secretaries responding to requests/inquiries in a timely manner.
• Assist physicians with Epic training and issues regarding record completion workflow.
• 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 deal professionally with co-workers, other departments, and medical personnel.
• Knowledge of various software packages.

Company Description