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Yale New Haven Hospital ยท 2 days ago
HIM Documentation Integrity Specialist
New Haven, CT
Full-time
Onsite
Entry, Mid Level
2+ years exp
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Responsibilities
From the Epic Analysis Needed work queue, analyzes the online 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. 1.1Highlight 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.
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 the status of incomplete medical records assigned to them for record completion. 2.1Reviews 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.
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. 3.1Reviews 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.
Provides assistance to physicians and secretaries responding to telephone and walk-in request/inquiries in a timely manner. Assists patients/customers in providing good customer service. Demonstrates acknowledgment of responsibility to practice and promote good customer relations and mutual respect 100 % of the time. 4.1Assists physicians with Epic training and issues regarding record completion workflow. 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.
From time to time will complete special projects as assigned by the supervisor or manager.
Qualification
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Required
Associates degree in healthcare related field or equivalent experience as a Documentation Integrity Technician
Two (2) to three (3) years of health information management experience required
Formalized training in medical record documentation requirements to ensure regulatory compliance
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
Preferred
RHIA or RHIT preferred
Licensure as RHIA or RHIT
Company
Yale New Haven Hospital
Yale New Haven Hospital (YNHH) is a 1,541 bed, not for profit academic medical center, and the primary teaching site for Yale School of Medicine and Yale School of Nursing.
10,001+ employees
Funding
Current Stage
Late StageLeadership Team
Marna P. Borgstrom
Chief Executive Officer
Michael Holmes, MSA
Executive Vice President, COO
Recent News
Hartford Business Journal
2024-04-07
Modern Healthcare
2024-04-07
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2024-04-07
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