Healthcare Documentation Integrity Auditor
Model Job Description
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 within the electronic health record is randomly reviewed for content and context with or without the benefit of providers’ voice files for comparison. An auditor compiles feedback for healthcare providers on critical and major errors that have the potential to impact document integrity and/or patient care, thereby eliminating repetition of errors. The auditor may request clarification from the clinician. Standard quality scoring criteria is utilized for fair and consistent evaluation. Statistics are maintained for trending purposes. This role supports a quality assurance program, which is different than the functions performed in a clinical documentation improvement program.
Skill Set
- 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 is a plus and recommended.
Training/Education
- Education – Associate’s degree or equivalent in terms of experience.
- Experience – Minimum of 3 years of experience in healthcare documentation and quality improvement.
- Preferred Credentials – Certified Medical Transcriptionist (CMT), Certified Healthcare Documentation Specialist (CHDS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA).
