HIM Documentation Integrity Specialist

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.

• 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.
• 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.
• 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.
• 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.

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.

• 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.
• 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.
• 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.
• 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.
• 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.

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.

• Reviews each…