HIM Documentation Integrity Specialist

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

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.
1.2. Click the Def Detective to review the summary of the patient's hospital stay and add or modify deficiencies to note any further work needed in the chart.
1.3. For any deficiency which has been amended or needs to be edited by the attending for missing information, attach a message using one of the departments Smart Text/Phrases.
1.4. When assigning deficiencies refer to hospital and department procedures and policies, and clinical department guidelines to accurately assign deficiencies to physician(s) responsible for completion of deficiencies.

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.

2.2. Before re-assigning a declined deficiency to another physician, reviews the audit trail of the edits that have occurred to a deficiency validating any other physicians who might have already declined. Reviews any messages from physicians that appeared in its earlier states.

2.3. Reviews deficiencies in the Done work queue which have been marked by physicians as completed. Verifies the documentation is complete and attach to the patient's chart. If the document is 'not' complete, send it back to the provider.

2.4. Reviews deficiencies in the Final Analysis work queue to make sure that all documentation is complete and all required information is present. Marks the chart episode as final or closed to remove it from the Incomplete Chart report.
2.5. 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.

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.
3.2. Follows up daily with physician's compliance with completion of delinquent deficiencies appearing on the Alert Letter sent to them for completion. Sends certified letters based on Alert Letters that have generated for records >14 days. Performs physician follow-up on prescribed schedule.
3.3. Upon approval, generates from Epic a Suspension of Admitting Privileges and Temporary Withdrawal of Clinical Privileges to the attending. Sends a copy of the letter to other designated individuals/departments as outlined in the HIM department policy and procedure. All suspension documentation, which includes fax confirmation is to be filed in the suspension book following the HIM department procedure and updates the
attending?s status in the Provider Report.
3.4. Checks daily to determine if physicians have completed their records. Once all records (delinquent and non-delinquent) assigned to the physician are completed, a Restoration Letter from Epic letter to attending and a copy of the letter faxed to other designated individuals/departments as outlined in the HIM department policy and procedure. Updates the attending?s status in the Provider Report.
3.5. Assists in any/all necessary deficiency report cleanup and analysis for all delivery networks.
3.6. Verifies and updates appropriate spreadsheets with new information as indicated.
3.7. Performs according to departmental productivity guidelines

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.

4.2. Works with physicians to ensure that all of the deficiencies in an episode are complete and properly documented according to quality standards.
4.3. Exercises good judgment when required to make a decision regarding the appropriate action to be taken, working independently to resolve issues before referring problems to the Senior Analyst/Supervisor.

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

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.