Job description
JOB SUMMARY
- The healthcare documentation integrity auditor ensures integrity of the electronic health record by monitoring, measuring and reporting on documentation created by healthcare providers. Documentation created with the electronic health record is randomly reviewed for content and context by a Certified Healthcare Data Specialists in medical language and healthcare documentation. The HDIA will interpret transcribed dictation by physicians and other healthcare professionals regarding patient assessment, workup, therapeutic procedures, clinical course, diagnosis, prognosis, etc., editing dictated material for grammar and clarity as necessary and appropriate. The process of medical editing of text that has been produced by speech recognition. This requires listening to dictation while reading a draft created via speech recognition technology and editing the text on a computer screen. This editing may range from minimal to extensive, depending on the capabilities of the speech recognition software and the dictating habits of the originator, and may include correction of content as well as punctuation, grammar, and style.
JOB REQUIREMENTS
- Minimum Education
- Associate’s degree or equivalent in terms of experience.
- Minimum Work Experience
- Minimum of 3 years of experience in healthcare documentation and/or quality improvement.
- Required Licenses/Certifications
- Certified Medical Transcriptionist (CMT)
- Certified Healthcare Documentation Specialist (CHDS)
- Required Skills, Knowledge, and Abilities
- Strong understanding of medical terminology, anatomy and physiology as well as disease processes
- Strong knowledge of HIPAA regulations, Joint Commission standards, and other healthcare regulatory bodies
- Excellent research skills
- Knowledgeable in all areas of documentation requirements
- Excellent written and oral communication skills
- Mastery of Microsoft Office products
- Knowledge of Clinical Informatics
- Knowledge of 3M ChartScript software, MModal Fluency direct for Transcription as well as Allscripts and IDX
- Designated Driver
- No
- OSHA Category
- 3 - Low Risk
Location: Hendrick Health · SS Health Information Services
Schedule: Full Time, Day Shift, Thursday - Monday 7am-330pm
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