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Under Construction - Career Map: Document Integrity Roles

 

Healthcare Documentation Integrity Auditor, Level 1 

Summary:

Healthcare Documentation Integrity Auditor, Level 1 audits and ensures the integrity of healthcare documentation created by physicians and other healthcare practitioners. Quality is monitored, measured and reported on by verifying content and contest for inconsistencies, discrepancies and inaccuracies. Level 1 auditors possess proficient medical knowledge, basic computer and Microsoft Office skills, and EHR familiarity. Nature of work performed may be limited in scope within community hospital settings, emergency departments or a specific medical specialty. AHDI certification is preferred (RHDS, CMT, or CHDS).

 

Educational Background:
  • High School Diploma or GED required
  • Vocational/Technical Healthcare Documentation/Transcription course preferred
  • Demonstrates continued educational credits in the healthcare documentation/medical field required

 

Experience Required:
  • More than 3-years healthcare documentation experience within a setting with limited scope such as a community hospital, emergency, ambulatory or certain medical specialty (radiology, cardiology, neonatal, etc.) 

 


Healthcare Documentation Integrity Auditor, Level 2 

Summary:

Healthcare Documentation Integrity Auditor, Level 2 audits and ensures the integrity of healthcare documentation created by physicians and other healthcare practitioners. Quality is monitored, measured and reported on by verifying content and contest for inconsistencies, discrepancies and inaccuracies. Level 2 auditors possess expert medical knowledge, advanced computer and Microsoft Office skills, and EHR mastery. Nature of work performed crosses all medical specialties in an acute care setting. AHDI certification is preferred (RHDS, CMT, or CHDS).

 

Educational Background:
  • High School Diploma or GED required
  • Vocational/Technical Healthcare Documentation/Transcription course preferred
  • Demonstrates continued educational credits in the healthcare documentation/medical field required

 

Experience Required:
  • More than 3-years healthcare documentation experience in a large acute care facility and/or quality assurance work in a large acute care facility

 


Healthcare Documentation Integrity Trainer/Educator 

Summary:

Healthcare Documentation Integrity Auditor/Educator audits and ensures the integrity of healthcare documentation with focus on physician training needs. Quality is monitored, measured and reported on by verifying content and context for inconsistencies, discrepancies and inaccuracies. Develops and conducts individual or classroom training of physicians and other healthcare practitioners in the entry of medical documentation into the EHR. Auditor/Educator individuals possess proficient medical knowledge, basic computer and Microsoft Office skills, and EHR mastery. AHDI certification is required within 1 year (CMT or CHDS).

 

Educational Background:
  • High School Diploma or GED required
  • Demonstrates continued education credits in the healthcare documentation/medical field required
  • Associate’s Degree in health care, quality management, or education (or equivalent education and experience) preferred 

 

Experience Required: 
  • More than 5-years’ experience with healthcare documentation in a large acute care facility and/or quality assurance work in a large acute care facility

 

 


Transcription Quality Assurance Specialist 

Summary:

Under the direction of the HIM Transcription Manager and in collaboration with the HIM Transcription Supervisors, develop and facilitate an on-going quality assurance program that provides consistent, reliable and measurable results that will enhance the skills and knowledge of HIM medical transcriptionists.

 

Educational Background:
  • Associate's Degree or its equivalent in terms of experience required

 

Experience Required: 
  • 3 years of experience medical transcriptionist in an acute care setting
  • Computer experience using Word and Excel or compatible software

 

 


Healthcare Documentation Integrity Auditor/Coordinator 

Summary:

Healthcare Documentation Integrity Coordinator acts as a lead team member providing assistance and/or education to healthcare documentation integrity auditors, healthcare documentation integrity auditor/educators and/or healthcare documentation specialists. Coordinator performs data analysis on audited results and assists in process improvement initiatives. Coordinator may perform documentation corrections and may communicate with clinicians. AHDI certification is required (CMT or CHDS).

 

Educational Background:
  • High School Diploma or GED required
  • Associate’s Degree or equivalent in terms of medical experience preferred
  • Demonstrates continued educational credits in healthcare documentation/medical field required

 

Experience Required:
  • More than 5 years’ experience with healthcare documentation in a large acute care facility and/or quality assurance work in a large acute care facility
  • Three years of experience in mentoring and instructing others

 


Healthcare Documentation Integrity Manager/Supervisor 

Summary:

Healthcare Documentation Integrity Manager/Supervisor manages the activities of the integrity auditors and educators. Provides education and guidance to the team based on utilizing data analysis and audited results. Manages process improvement initiatives. May serve on various hospital committees such as Quality or HIM.  May work with physicians, other managers and C-suite executives on various hospital quality initiatives.

 

Education Background:
  • Healthcare Information Management degree or in related field preferred
  • Associate degree and equivalent experience required
  • Demonstrate willingness for continuing education required

 

Experience Required:
  • Minimum 5 years’ experience working as a QA manager in a large healthcare organization

 


 

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