HIM Documentation Integrity Specialist - DCH Health System

  The HIM Documentation Integrity Specialist is responsible for ensuring the integrity of the electronic health record by monitoring, measuring and reporting on documentation created by healthcare providers.  Documentation created within the electronic health record will be randomly reviewed for content and context.  The specialist will compile feedback for providers on critical and major errors that have the potential to impact document integrity and/or patient care, thereby eliminating the repetition of errors.  Standard quality scoring criteria are utilized for fair and consistent evaluation.  Statistics are maintained for trending purposes.  This role supports the DCH quality improvement program.

1. Conducts random reviews of medical and surgical records to ensure compliance with JCAHO, CMS and DCH Medical Staff Rules and Regulations pertaining to provider documentation.
2. Identifies patterns of noncompliance and conducts focused reviews as needed.
3. Generates reports and communicates results and activities to administration, medical staff and other internal and external parties to support organizational improvement initiatives.
4. Provides follow up communications and education to providers on their individual results.
5. Serves as a resource on documentation requirements for all providers.
6. Creates educational materials as needed.
7. Maintains documentation review spreadsheets and/or Midas databases for documentation improvement.
8. Assists with revision of electronic record documentation as needed due to patient identity or account issues.
9. Meet and maintain established individual goals per departmental policies.
10. Consistently meets or exceeds departmental deadline standards and work/project completion (i.e. individual productivity, meeting established deadlines)
11. Demonstrates a commitment to the provision of high quality service and contributes to quality outcomes (i.e. accuracy rates, documentation, quality improvements).

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

1. Ability to work independently, and manage multiple projects, with strong prioritizing skills.
2. Strong understanding of medical terminology, anatomy and physiology, and disease processes.
3. Strong knowledge of HIPAA regulations, Joint Commission standards, CMS COP standards and other healthcare regulatory bodies in terms of medical documentation requirements.
4. Basic knowledge of data analysis.
5. Excellent research skills.
6. Excellent written and oral communication skills.
7. Education – Minimum of Associate’s degree in Health Information Technology or other related healthcare field and/or equivalent in terms of experience.
8. Preferred Credentials – Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) preferred.

WORKING CONDITIONS

WORK CONTEXT

1. Requires ability to work 8 hours quietly at a computer screen and keyboard/mouse.
2. Requires accuracy and attention to detail. 
3. Requires ability to withstand pressures of constant deadlines, audits, educational demands and changing healthcare environment.
4. Must be able to adapt to changes in work area as assigned. 
5. Displays a willingness to take on responsibilities and challenges.
6. Must have the ability to accept criticism and dealing calmly and effectively with high stress situations.
7. Hybrid work environment with flexible hours. 

PHYSICAL FACTORS

1. This job involves standing, walking, sitting, stooping, pushing, pulling, and crouching.
2. The job is considered light work.
3. Ability to lift up to 20 pounds occasionally and 10 pounds frequently and/or negligible amount of force constantly to move objects frequently.
4. Hearing and vision must be normal or corrected to within normal range. 
5. Must have good dexterity and should be able to reach and extend arms in any direction.
6. Physical presence onsite may be required.
7. Must be able to perform the duties with or without reasonable accommodation.