Document Integrity Specialist

Overview

Performs ongoing review and monitoring of electronic health record documentation to ensure compliance with documentation integrity standards, including identification of inappropriate copy/paste utilization, cloned documentation, conflicting information, missing authentication, and other documentation quality concerns. Conducts audits, analyzes trends, facilitates corrective actions, and collaborates with providers, CDI, Coding, Compliance, and operational leaders to improve the accuracy, completeness, reliability, and integrity of the legal health record.

• Accurate alphabet and numeric filing skills are essential.
• Strong knowledge of regulatory and governing agencies, CMS, IDPH, HHS, HIPAA, and DNV, in collaboration with other governing entities.
• Knowledge of, or willingness to learn, Riverside Healthcare's medical record documentation bylaws and policy requirements in collaboration with other required Riverside Healthcare policies and procedures.
• Polished communication and customer relation skills.
• Medical terminology preferred.
• Previous clerical experience in a hospital setting highly preferred.
• Detail-oriented, critical thinking, committed to accuracy, and ability to solve problems.
• Strong knowledge of HIPAA, federal, and state regulations regarding release of protected health information.
• High school graduate or equivalent; prior experience in related field, associate's degree preferred.

• Conduct documentation integrity reviews to ensure the medical record is complete, accurate, reliable, and compliant with federal, state, accreditation, and organizational requirements.
• Monitor electronic health record (EHR) documentation for inappropriate copy-forward/copy-paste practices, cloned documentation, conflicting information, missing authentication, and other documentation quality concerns.
• Perform documentation quality audits and report findings, trends, and opportunities for improvement to HIM leadership and designated stakeholders.
• Collaborate with providers, Coding, Clinical Documentation Integrity (CDI), Compliance, Revenue Cycle, Information Systems, and operational departments to resolve documentation deficiencies and integrity concerns.
• Facilitate corrective actions related to documentation quality, chart corrections, amendments, and record completion activities according to organizational policies and regulatory requirements.
• Support organizational initiatives related to information governance, documentation quality, regulatory readiness, and legal health record management.
• Participate in education and training efforts related to documentation standards, documentation integrity, authentication requirements, and appropriate use of EHR functionality.

• Strong knowledge of medical terminology, documentation standards, and regulatory requirements.
• Proficiency in Microsoft Office Suite (Word, Excel, Outlook) and experience with electronic health record (EHR) systems.
• Excellent attention to detail and organizational skills with the ability to manage multiple tasks and priorities effectively.
• Strong communication skills, both verbal and written, with the ability to work collaboratively in a team environment.
• Demonstrated ability to handle confidential information with discretion and integrity.

• None

• Bachelor's degree is preferred
• Certification as a Registered Health Information Technician (RHIT) or Certified Professional Coder (CPC) is highly desirable

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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