Career Map: Level 3
Application System Analyst
Summary:
Under direct supervision, assists in responding to requests from users for new or modified systems. This may involve planning, designing and analyzing various programs or software such as an Enterprise Master Patient Index (EMPI), which is a database that is used across a healthcare organization to maintain consistent, accurate and current demographic and essential medical data on the patients seen and managed within its various departments. May help in the consultation with users to identify current operating procedures for single departmental changes, define system requirements, and determine programming and/or application functionality requirements. Learns to create technical and procedural designs for new or revised applications, including system specifications and programming guidelines. May assist in the documentation to describe application changes for program development and corrections.
Educational Background:
- Associate’s degree/technical school or equivalent required
- Bachelor’s degree or equivalent required
Experience Preferred:
- Three years of experience in field
- Experience in systems development lifecycle, including requirements, gathering, and design
- Background in healthcare sciences or information systems
Department Physician Coordinator
Summary:
Serve as HIM, IT or Healthcare Documentation Department liaison to physicians. Provide front-line customer service while building relationships with the physician groups. Duties will depend upon the individual area and the responsibilities required to serve the physician community.
Educational Background:
- Minimum of associate’s degree required
- Bachelor’s degree preferred
Experience Required:
- Minimum three years’ experience in a similar role
EHR/SR Trainer
Summary:
Individual who has knowledge of technology and the common work flow/requirements of healthcare documentation. Assists in the preparation and transitioning process and training of staff and clinicians of the appropriate use of new systems/tools. Develop and assist with creation of templates and macros, perform training sessions for new staff, and address groups of incoming residents/HIM staff. Provide feedback to EMR/EHR developers for product improvements.
Educational Background:
- RHIT or equivalent (HIM data analyst)
Experience/Skill Sets:
- Healthcare background
- Strong computer skills with possible continuing education required in basic IT support to enhance
- ability to train others
- Strong communication skills
- Knowledgeable in all areas of documentation requirements
- Good “troubleshooting” skills as well as skill in the healthcare documentation process
- Highly organized and detail-oriented
Patient Portal Liaison
Summary:
Process, maintain, and review various work queues within the EHR platform. Provide front-line support and customer service followup to patients. Gather data and maintain spreadsheets. Duties and Responsibilities include processing assigned EHR work queues/modules and in-basket folders to process both clinical results and/or clinical documentation timely. Monitor and process organizational distribution/faxing platform for errors and resolve related issues.
Educational Background:
- Minimum of high school diploma or GED required
- Associate’s degree preferred
Experience/Skill Sets:
- Minimum of three to five years’ equivalent experience required
- Six to ten years’ equivalent experience preferred
- Customer service oriented with excellent interpersonal and critical thinking skills
- Extensive medical transcription/healthcare documentation knowledge required
- Microsoft Office and associated dictation/transcription technology required
- Healthcare background and related experience in EHR functionality and HL7 interfaces preferred
Healthcare Documentation Specialist 3
Summary:
Healthcare Documentation Specialist, Level 3, transcribes and/or edits patient healthcare documentation dictated by physicians and other healthcare practitioners. Level 3 individuals possess proficient knowledge in the field of healthcare documentation. Nature of work performed crosses all medical specialties in a large acute care setting. Individuals may perform QA tasks, mentor peers, and/or assist with projects. AHDI certification is preferred (RHDS, CMT, or CHDS).
Educational Background:
- High school diploma or GED required
- Vocational/technical healthcare documentation/transcription training required
- Demonstrates continued educational credits in the medical field required
Experience Required:
- More than three years’ healthcare documentation experience at a large acute care facility, with knowledge and expertise ranging across multiple medical disciplines and specialties
Senior Medical Scribe
Summary:
In addition to the regular duties of a medical scribe, the senior medical scribe acts as an onsite supervisor and liaison. The senior medical scribe provides administrative support and quality assurance while ensuring proper staffing levels/shift coverage/training support. The senior medical scribe mentors up to 30 scribes. They serve as a local point contact with the facility, ensuring effective two-way communication between the scribes and the facility. May require some travel between facilities.
Educational Background:
- College graduate, student enrolled, or interested in pursuing a healthcare professional career.
- Exceptions made for individuals with equivalent experience.
- Healthcare-related credential preferred
Experience Required:
- Successful completion of a Medical Scribe program
- Experience in delivering client-focused solutions based on customer needs preferred
- Leadership experience preferred
- Teaching/mentoring experience preferred
- Strong computer skills required
Healthcare Documentation Specialist Supervisor
Summary:
Supervises and oversees the daily activities of the HIM Healthcare Documentation department and its practitioners to ensure the timely delivery of quality services. Coordinates and monitors day-to-day transcription operations. Oversees training of staff and provision of resources to staff. Is knowledgeable about all equipment and applications used and can troubleshoot issues as needed. Maintains and follows policies and procedures, complies with local, state, and federal employment laws affecting employees and independent contractors, and assumes responsibility for ensuring that all programs are administered according to facility standards and applicable regulatory compliance.
Educational Background:
- High school diploma or GED required
- Associate’s or bachelor’s degree preferred
- An equivalent combination of relevant education and experience may be considered in place of degree
- Vocational/technical healthcare documentation/transcription training required
- RHDS or CHDS preferred
- Demonstrates continued educational credits in the medical field preferred
Experience Required:
- Three to five years of related healthcare documentation specialist experience, preferably in an acute care setting and in a lead, supervisory and/or quality auditor capacity
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 three 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 one 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 five 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 five 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
Coder II
Summary:
Reports to the Ancillary Coding Manager. Reviews all pertinent documentation, including but not limited to: physician documentation, nursing documentation, laboratory and radiology reports, treatment records, and other documentation within the electronic medical record. Selects and sequences appropriate diagnostic codes utilizing ICD-9 CM and/or ICD-10 CM codes: Ancillary Coding – ICD-9/ICD-10 diagnostic and Ancillary Coding – ICD-9/ICD-10 diagnostic coders.
Educational Background:
- High school diploma or GED required
- Registered Health Information Technician required
- Bachelor’s degree or Registered Health Information Administrator preferred
Experience Preferred:
- Two to three years’ experience
HIM Analyst
Summary:
Responsible for maintaining accuracy of electronic medical records with minimal deficiencies and errors. Analyzes and reviews records for required elements and assigns deficient records to appropriate provider for completion. Assures complete and accurate maintenance of key patient data in the EHR information systems. Understands how the various registration and clinical systems interface to trouble-shoot and determine the appropriate course of action when errors are identified. Exercises a high degree of responsibility, problem-solving ability, analytical skills, initiative, and good judgment in resolving duplicate patient records and missing or erroneous data in patient records, including both the EHR and the paper record. May evaluate quality and productivity metrics. May act as liaison to providers to facilitate completion of records in a timely manner.
Educational Background:
- Associate’s degree or equivalent combination of relevant education and experience required
Experience:
- Two years of HIM record system evaluation experience, preferably in an acute care setting
- RHIT preferred
HIM IS/IT Data Analyst
Summary:
Maintains accountability for managing software/data needs and technical services for area of accountability, in collaboration with HIM and Technology and Information Solutions (TIS) staff. Performs the initial analysis of data, develops customized reports to facilitate meaningful interpretation of the data, and provides education support to users.
Educational Background:
- Bachelor’s degree or equivalent combination of education and experience required
Experience Required:
- Two years of related and relevant experience
- Experience with multiple software packages
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