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Posted in Other 30+ days ago.

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Type: Full Time
Location: New Haven, Connecticut

Job 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.

The Documentation Quality Specialist is responsible for monitoring the integrity of the clinical data entered into the electronic health record systems. This will be performed through ongoing auditing and monitoring practices to insure documentation standard and regulatory requirements are consistently applied. Performs a variety of specialized activities in support of quality assurance and auditing functions of incomplete/delinquent records. Pays meticulous attention to detail and have proficient knowledge of the electronic health record (Epic) in order to be able to assist with review, identification, capturing, and reporting of specific deficiencies. Works closely with the physicians to ensure accurately and timely completion and reporting of incomplete and delinquent medical records. Assist the physicians and analyst with Epic training and issue with regarding record completion work flow.



* 1. Monitors and analyzes specific deficiency queues as assigned. Conducts chart audits for specific analyzation criteria as needed.

* 1.1 Identifies, analyzes, and interprets trends or patterns in reports.

* 2. Ensures timely and accurate statistical reporting and notification to physicians on status of incomplete/delinquent medical records. Determine completeness and accuracy of information as prescribed by hospital regulations, the Joint Commission of Accreditation of Health Care Organizations and appropriateness state/federal regulations initiating appropriate action to correct any deficiencies noted.

* 3. Ensures adherence to hospital procedure regarding timely completion of delinquent medical records as outlined in the Hospital Bylaws. Follows the department guidelines notification and suspension of physicians who fail to complete their records within the required timeline.

* 3.1 Reviews each deficiency on the physician*s Alert Letter of Delinquent Medical records assigned to them for monitoring. Reviews the Epic documentation to ensure that each deficiency is assigned to the correct physician(s), the deficiency status is accurate and that it is under the correct visit.

* 4. Reviews records for Operative Report and Discharge Summary compliance.

* 4.1 Runs daily reports for incomplete Discharge Summaries 24hrs. Pushes the physician notification letter.

* 5. Performs other related duties and special assignments as requested and directed by the supervisor or manager. Assists supervisor with training of staff in changes and new procedures.

* 5.1 Willingly accepts reassignment to other duties or special assignments as requested by supervisor or manager when need arise to meet staffing and production requirements.

* *cb



Associates degree in health care related field or equivalent experience as a Documentation Integrity Specialist. RHIA/RHIT certification preferred.


Three (3) years of health information management experience with extensive knowledge of Joint Commission standards, CMS regulations, and medical staff bylaws.


RHIA/RHIT certification preferred.


Requires knowledge of medical terminology and a thorough knowledge of a variety of regulations concerning the content of Medical Records. 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.