At UW Health in northern Illinois, you will have :

• Competitive pay and comprehensive benefits package including : PTO, Medical, Dental, Vision, retirement, short and long-term disability, paternity leave, adoption assistance, tuition assistance
• Annual wellness reimbursement
• Opportunity for on-site day care through UW Health Kids
• Tuition reimbursement for career advancement ask about our fully funded programs!
• Abundant career growth opportunities to nurture professional development
• Strong shared governance structure
• Commitment to employee voice

POSITION SUMMARY :

The Document Integrity Specialist performs a variety of tasks associated with the collecting, analyzing and indexing of patient care documentation in the medical record.

Application of knowledge includes the process to store, retrieve, review, analyze, and process health-related information.

The incumbent in this position is required to be well versed with varying State, Federal, regulatory and accreditation requirements.

Incumbents must document HIM activities following applicable guidelines and regulations. The incumbent may work closely with both internal and external customers including clinicians, staff, vendors and patients.

Medical records may exist in paper or electronic form and a wide variety of health record indices and computer databases may be utilized.

Work is performed under the supervision of the Document Integrity Supervisor

EDUCATION / TRAINING :

Minimum :

General Education Diploma (GED)

Preferred : High School Diploma

High School Diploma

LICENSURE / CERTIFICATION :

Minimum : N / A

N / A

Preferred :

RHIT or RHIA preferred

EXPERIENCE : Minimum :

Minimum :

One year of progressively responsible Health Care related experience required. Education in Health Information Management may be substituted for years of experience.

Preferred :

REQUIRED SKILLS, KNOWLEDGE, AND ABILITIES :

• Excellent verbal and written communication skills
• Knowledge of indices and filing systems necessary to file, store, and retrieve information from paper and electronic record systems preferred (terminal digit filing preferred)
• Ability to examine the record and verify patient identification
• Ability to examine a document and determine its proper placement within the paper or electronic record
• Knowledge of standard medical terminology, basic human anatomy and medical record format, content and medical documentation order preferred.
• Detail orientated and ability to be self-motivated to prioritize and make decisions to complete duties in a timely manner.
• Ability to work under pressure of deadlines.
• Excellent interpersonal communication and team skills in a complex organizational setting.
• Excellent internal and external customer service skills with the ability to remain calm, be patient and respond professionally to all requests
• Ability to work in a team environment and to collaborate with a variety of professionals
• Knowledge of and experience with conflict resolution techniques and problem analysis / resolution skills preferred
• Knowledge of UW Health organizational structure preferred
• Proficient in the operation and use of computers and scanners including various software programs such as Epic, word processing and spreadsheets
• Ability to perform routine maintenance and basic maintenance of scanning equipment preferred
• Ability to maintain patient and employee confidentiality
• Ability to work scheduled on-call as needed
• Ability to perform repetitious movement, including long periods of standing or sitting, along with the ability to stoop, bend, reach, step up and sit for extended periods of time.
• Ability to lift 10 pounds.
• Ability to perform job function and make decisions without direct supervision

MAJOR RESPONSIBILITES :

Document Integrity

• Provide training and direction to health care staff regarding medical record completion, management and confidentiality requirements.
• Contact physicians and other health care staff as needed to remedy identified record deficiencies or corrections.
• Release of the required documents upon completion of the specific documents electronically or manually.
• Review scanned documentation for quality, accuracy and completion of required documents
• Monitor daily reports and act upon them within the priorities established by management
• Follow statutory guidelines and other regulations to independently evaluate completion of records.
• Receives incoming phone calls and acts according to needs of callers.
• Evaluate active and discharge medical record for both completeness and quality of documentation.

Administrative

• Provide Manager / Supervisor with suggestions for improvement in workflows
• Actively participate in process improvement, engagement, department, staff and other work meetings / teams.
• Maintain knowledge of and adhere to all HIPPA, confidentiality and compliance regulations, rules, guidelines, policies and procedures.

ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS.

Our Commitment to Diversity, Equity, and Inclusion

UW Health is committed to being a diverse, inclusive and anti-racist workplace and is an Equal Employment Opportunity, Affirmative Action employer.

Our integrity shines through in patient care interactions and our daily work practices as we work to embrace the knowledge, unique perspectives and qualities each employee and faculty member brings to work each day.

Applications from Black, Indigenous and People of Color (BIPOC) individuals, LGBTQ and non-binary identities, women, persons with disabilities, military service members and veterans are strongly encouraged.

EOE, including disability / veterans.

PI248108785

Last updated : 2024-08-24