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.
Experience and Education Requirements
- 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.
Key Responsibilities
- 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.
Responsibilities
Required Experience
- 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.
Required Licensure/Education
Preferred Education
- 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.
Our Commitment to You:
Riverside Healthcare offers a comprehensive suite of Total Rewards: benefits and nationally rated employee well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so your journey at and away from work is remarkable. Our Total Rewards package includes:
Compensation:
- Base compensation within the position’s pay range based on factors such as qualifications, skills, relevant experience, and/or training
- Premium pay such as shift differential, on-call
- Opportunity for annual increases based on performance
Benefits - .5 to 1.0 FTE:
- Paid Time Off programs
- Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
- Health Savings and Flexible Spending Accounts for eligible health care and dependent care expenses
- Defined contribution retirement plans with employer match and other financial wellness programs
- Educational Assistance Program
Benefits - .001 to .49 FTE:
- Paid Leave Hours accrued as you work
Employee Health Requirements:
Exposure to:
- Chemicals: Printer, copier, fax toners; liquid paper; scanner cleaning kit and materials.
- Video Display Terminals: Extreme.
- Blood and Body Fluids: None.
- TB or Airborne Pathogens: None other than normal hospital environment exposure.
Sensory requirements (speech, vision, smell, hearing, touch):
- Speech: Telephone and in-person communication with customers, physicians, staff, and peers.
- Vision: View computer screen, medical records, and reports; access and review hard copy and online references and resources; file and retrieve records; identify and copy requested documents; prepare and distribute reports; prep, scan, and index records; conduct quality reviews.
- Smell: Common office environment
- Hearing: Telephone and in-person communication with customers, physicians, staff, and peers; hear and respond to telephone, overhead pages, and emergency announcements; participate in in-service and continuing education programs.
- Touch: Write; keyboard; file/retrieving documents, reports, and records; photocopy; prepare and distribute reports and records; prep, scan, and index medical records and other associated documents; conduct quality reviews of HPF activities.
Average Hours per Week: 40+ Shift: Varies
Percentage of Time During the Normal Workday
Activity Percentage Activity Percentage
Sit 70% Twist 1%
Stand 5% Crawl 1%
Walk 5% Kneel 2%
Lift 5% Drive 1%
Squat 3% Climb 1%
Bend 3% Reach above shoulders 3%
Weight Required to Be Lifted During the Normal Workday
Weight Frequency
Up to 10 lbs. Frequently
Up to 20 lbs. Frequently
Up to 35 lbs. Frequently
Up to 50 lbs. Occasionally
Up to 75 lbs. Not Required
Up to 100 lbs. Not Required
Over 100 lbs. Not Required
Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.): Stacks of charts, supplies carried.
waist high approximately 300 ft. May have to carry records up/down circular staircase. Carrying, lifting, and bending with charts to file, retrieve, or pull from various department locations to prep/scan/index/review. Carrying paper/file folders through department. Reams of paper to printers/photocopier.
Maximum Consecutive Time During the Normal Workday
Activity Minutes Activity Minutes
Sit 240 Twist 5
Stand 15 Crawl 2
Walk 15 Kneel 5
Lift 5 Drive 15
Squat 5 Climb 10
Bend 5 Reach above shoulders 5
Repetitive use of hands (Frequency indicated):
- Simple grasp up to 10 lbs.
- Normal weight: 5-10 Lbs. regularly.
- Pushing & pulling Normal weight: 3-9 Lbs. frequent.
- Manipulation: Writing instruments, clips, fasteners, stapler and staple remover; keyboarding, filing/retrieval, copying, prep/scan/index, record review, and sorting.
- Repetitive use of foot or feet in operating machine control: None.
Pay Range
USD $22.14 - USD $27.39 /Hr
