Career Map: Document Integrity Roles
Clinician-Created Documentation Integrity Auditor 1
Summary:
Clinician-Created 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 context 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.)
Clinician-Created Documentation Integrity Auditor 2
Summary:
Clinician-Created 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 context 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
Clinician-Created Documentation Integrity Auditor Educator/Trainer
Summary:
Clinician-Created Documentation Integrity Auditor Educator/Trainer 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/trainer individuals possess proficient medical knowledge, basic computer and Microsoft Office skills, and EHR mastery. Current AHDI certification (CMT or CHDS) is required or must be earned (CHDS) within 1 year.
Educational Background:
- High school diploma or GED required
- Continued education credits earned 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
Quality Assurance Specialist
Summary:
Under the direction of the HIM Healthcare Documentation manager and in collaboration with the HIM Healthcare Documentation 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 healthcare documentation specialists.
Educational Background:
- Associate’s degree or equivalent experience required
Experience Required:
- Three years of healthcare documentation experience in an acute care setting
Computer experience using Word and Excel or compatible software
Clinician-Created Documentation Integrity Coordinator
Summary:
The Healthcare Documentation Integrity Coordinator acts as a lead team member aiding and/or educating healthcare documentation integrity auditors, healthcare documentation integrity auditor educators/trainers, 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 medical experience preferred
- 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
Clinician-Created Documentation Integrity Supervisor/Manager
Summary:
Clinician-Created Documentation Integrity Supervisor/Manager manages the activities of the integrity auditors and educators. Provides education and guidance to the team based on 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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