Job Summary: Health Information Analyst focused on medical record auditing, clinical coding, and healthcare quality improvement. Key Highlights: 1. Clinical statement analysis and coding 2. Medical record audit for healthcare quality assurance 3. Ensuring accurate DRG assignment **None:** Brief job description A Health Information Analyst is a professional of paramount importance to healthcare institutions, primarily responsible for analyzing clinical statements and applying standard coding systems. Reviews patient records to determine whether a condition was present on admission or not, identifies issues related to inconsistent, missing, conflicting, or unclear documentation to be resolved by the attending physician. Diagnoses non-conformities in the care process through medical record audits, aiming to enhance healthcare quality while reducing waste and improving operational outcomes. Mandatory Requirements Bachelor's degree in Nursing; Active Regional Nursing Council (COREN) registration; Completed or ongoing specialization in hospital auditing; Experience in nursing care; Intermediate proficiency in Microsoft Office suite. **Desirable Requirements:** Experience in hospital auditing; Specializations (hospital management, obstetrics, neonatology, hemodynamics, emergency and critical care, oncology, nephrology); Familiarity with the DRG Brazil platform. **Specific Knowledge:** Knowledge of ICD, TUSS tables, and CBHPM; Solid knowledge of medical terminology, anatomy, pathophysiology, and pharmacology; Technical expertise and familiarity with various areas related to audited activities (clinical, surgical, pediatric, obstetric, oncologic, hemodynamic, and intensive care unit admissions); Knowledge of hospital cost structures. Required Technical Skills / Required Technical Procedures Critical thinking; Systems thinking; Time management. Problem solving; Creativity and innovation; Results orientation; Emotional intelligence; Accountability; Analytical skills; Communication skills. Duties and Responsibilities Conduct rigorous medical record audits to verify technical compatibility, quality, and efficiency of care; Code admissions and discharges in the DRG Brazil platform; Code all health data completely and accurately, in accordance with regulatory standards and applicable requirements and legislation; Code only those codes and data clearly and consistently supported by documentation in the medical record according to the appropriate coding system, requesting clarifications when necessary and additional documentation prior to code assignment when conflicts arise or information is incomplete or ambiguous; Ensure accurate DRG assignment—a critical decision directly impacting reimbursement rates and performance metric generation—whereby physician documentation must serve as the definitive basis for final selection; Review medical records to locate documentation clarifying the final diagnosis recorded on the admission sheet and/or discharge summary, potentially resulting in assignment of a more specific code number; Adopt precise, complete, and consistent practices for generating high-quality health data; Advance coding knowledge through continuing education; Understand disease processes, anatomy, physiology, pharmacology, clinical documentation, and the entire framework governing diagnostic and procedural coding to effectively draw conclusions from information documented by physicians; Continuously protect the confidentiality of health records and refrain from accessing protected health information not required for coding activities (LGPD Law); Demonstrate integrity, reflecting commitment to ethical and legal coding practices and reinforcing professional trust; Interact with multidisciplinary teams; Participate in the Patient Safety Committee and Medical Record Commission; Analyze overall DRG performance reports and participate in economic and clinical opportunity meetings with providers; Contribute to hospital accreditation projects; Maintain updated protocols, guidance manuals, procedures, and work routines in compliance with current legislation to ensure adherence to regulations; •Report infectious and non-infectious adverse events via the DRG platform and provider’s system; Attend monthly management meetings; Collaborate with the team in maintaining workplace equipment and supplies. **None:** None
João Silva
Indeed · HR
João Silva
Indeed · HR
