Documentation Integrity Specialist at Yale New Haven Health in New Haven, Connecticut

Job Description:

OVERVIEW 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.

EEO/AA/Disability/Veteran

RESPONSIBILITIES

* 1. From the Epic Analysis Needed work queue, analyzes the on line medical record for inpatient, ambulatory surgery, and/or emergency department patients as well as various outpatient encounters. Determines completeness and accuracy of information as prescribed by hospital regulations, the Joint commission on Accreditation of Health Care Organizations and appropriateness state/federal regulations initiating appropriate action to correct any deficiencies noted.

* 1.1 Highlight the assigned discharge in the Analysis needed work queue and open the Episode to review the Deficiency Completion activity for the discharge. Review the Summary tab and the Deficiency tab to view a summary of the episode and details regarding each deficiency.

* 2. 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.

* 2.1 Reviews deficiencies in the Declined work queue which the physician has declined and the reason. Based on the documentation in Epic make the decision to complete, reassigns to another physician or sends back the deficiency to the physician.

* 3. Ensures adherence to hospital procedure regarding timely completion of delinquent medical records as outlined in the Hospital By Laws. Follows the department guidelines for 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. Provides assistance to physicians and secretaries responding to telephone and walk-in request/inquires in a timely manner. Assists patients/customers in providing good customer service. Demonstrates acknowledgement of responsibility to practice and promote good customer relations and mutual respect 100 % of the time.

* 4.1 Assists physicians with Epic training and issues with regarding record completion work flow. Supplies Epic Tip Sheets when needed and serves as the physician liaison. Answers policy and procedure questions regarding record assignment/completion trying to resolve the issue or return the call by the end of the day supplying or updating the physician or the office with the appropriate information.

* 5. From time to time will complete special projects as assigned by the supervisor or manager.

QUALIFICATIONS

EDUCATION

Associates degree in healthcare related field or equivalent experience as a Documentation Integrity Technician; RHIA or RHIT preferred.

EXPERIENCE

Two (2) to three (3) years of health information management experience required; formalized training in medical record documentation requirements to ensure regulatory compliance.

LICENSURE

RHIA or RHIT preferred.

SPECIAL SKILLS

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.