Yale New Haven Health System

SR. DOCUMENTATION QUALITY SPEC

US-CT-New Haven
Job ID
63480
Department
DOCUMENTATION INTEGRITY
Category
ADMIN/CLERICAL
Position Type
Full Time Benefits Eligible
Scheduled Hours
40
Work Schedule
DAYS
Work Days
MONDAY - FRIDAY
Work Hours
8AM - 4:30PM
Work Shift
NONE
Requisition ID
2017-17280

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.

The Senior Documentation Quality Specialist is responsible for monitoring the integrity of the clinical data entered into the electronic health record system. This will be performed through ongoing auditing and monitoring practices to insure documentation standards and regulatory requirements are consistently applied. Assists the Senior Manager with the processing of patient amendment requests to ensure timely responses in accordance with compliance policies and federal regulations. Performs a variety of specialized activities in support of quality assurance and auditing functions. Collates data to track findings and identify trends. Pays meticulous attention to detail and has proficient knowledge of the electronic health record (Epic) in order to assist with review, identification, capturing, and reporting of specific deficiencies.
Works closely with physicians to ensure accurate and timely completion and reporting of amendment requests as well as incomplete and delinquent medical records. Works closely with patients regarding inquiries about the patient chart amendment process. Assists physicians and Documentation Integrity Specialists with Epic training and issues regarding record completion work flow.

EEO/AA/Disability/Veteran

Responsibilities

  • 1. Monitors and analyzes specific deficiency queues as assigned. Conducts chart audits for specific 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. Determines completeness and accuracy of information as prescribed by hospital regulations, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and appropriate state/federal regulations initiating appropriate action to correct any deficiencies noted.
    • 2.1 Tracks amendment requests received by facility and notifies Senior Manager of their receipt.
  • 3. Ensures adherence to hospital procedures regarding timely completion of delinquent medical records as outlined in the respective Hospital Bylaws. Follows the department guidelines notification and enforcement processes 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 compliance.
    • 4.1 Runs weekly report for missing operative reports greater than 7 days and pushes the physician notification letter.
  • 5. Performs other related duties and special assignments as requested and directed by the Senior Manager.
    • 5.1 Assists with training of staff in changes and new procedures.

Qualifications

EDUCATION


Associate's degree in a healthcare related field required. RHIA/RHIT certification required or within one year in this position.


EXPERIENCE


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


LICENSURE


RHIA/RHIT certification required or within one year in this position.


SPECIAL SKILLS


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.


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