Job Summary
This position is responsible for reviewing the medical record for completeness, timeliness, and accuracy against the according to standards established by the Medical Staff Rules and Regulations, outside regulatory agencies, and departmental procedures upon patient discharge. Identify whether all required documentation is present and that all entries have been authenticated before the record is filed as complete. Assign identified deficiencies to the responsible provider(s) for timely complete. Perform re-analysis, to ensure the deficiencies were taken off by the assigned provider and that assigned deficiencies are accurate.
Responsibilities
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified. Analyzes and assigns chart deficiencies to the appropriate provider(s) based on Medical Staff Rules and Regulations as well as federal and state regulatory guidelines for medical record documentation. Adheres to established Mon Health Medical Center standards/policies and system workflow guidelines to add and re-assign accounts to appropriate work queues for processing. Ensures integrity of the legal medical record. Performs Adjust Document Index functions via the deficiency management system. Verifies correct indexing of the MRN, account number, and/or document type. Verifies quality and correctness of all scanned images from the imaging vendor and the facility. Actively maintains 72-hour TAT for various analysis-specific work queues, electronic and manual, to ensure timely analysis and chart completion. Identifies documents needing to be re-scanned due to poor image quality and routes those documents to the appropriate work queue for processing. Communicates via established protocols to local HIM Manager and the Director of HIM for missing documents and other needs requiring local facility intervention to complete quality integrity review. Addresses appropriate questions related to medical record completion from the HIIM Manager, HIM Supervisors, Facility HIMDs, Physicians and/or other providers. Meets or exceeds corporate quality standard of 95% or greater on all audited medical records. Assists in maintaining all equipment and supplies required to provide services in an optimal manner. Promptly reports issues and trends not complying with facility or corporate policies/standards. Assists in cross-training other employees, as necessary. Able to work independently as a onsite or remote employee. Performs other duties as assigned. Provide assistance in Release of Information to help with any backlog needs. Provide assistance in the Scanning area when needed.
Knowledge, Skills & Abilities
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Requires prolonged sitting, some bending, stooping, and stretching. Requires eye-hand coordination and sufficient manual dexterity to operate a keyboard, photocopier, telephone, calculator, and other office equipment. Requires normal range of hearing and eyesight.
Minimum of 1-year previous experience in a hospital Health Information Management Department. Two years previous experience in a hospital Health Information Management Department with additional experience in quality analysis or similar function preferred. Strong analytical and organizational skills; filing systems; ability to prioritize workloads, meet deadlines and work effectively under pressure; excellent customer service skills; general office procedures; ability to problem solve and work under minimal supervision; familiar with basic medical terminology; familiar with chart completion requirements from a variety of sources including medical staff rules and regulations and outside regulatory agencies; computer skills.
Education
• High School Diploma or GED (Required)
• Associate's Degree
Credentials
Work Schedule: Days
Status: Full Time Regular 1.0
Location: 99 J D Anderson
Location of Job: WV:Morgantown:Mon Health Medical Center
Talent Acquisition Specialist: Guy S. Stewart