Analyzes, abstracts, and reviews, inpatient, same day surgery, emergency room, Chestnut Ridge inpatient and observation charts to ensure completeness for billing, TJC, Corporate Compliance Plan, HCFA documentation requirements, WVMI, ACOS, and other accrediting agencies and third party providers. Responsible to ensure proper validation and authorization for requests for release of protected health information from WVUH properties in various media formats. Responsible to ensures proper document capture and documentation correction for protected health information in all hospital systems as appropriate.
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
High School Education or Equivalent required.
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
Graduate from an accredited program in Health Information Technology (HIT), preferred.
Eligible to take the Registered Health Information Technicians Examination (RHIT). May be waived for five years of relevant HIM department experience in imaging, billing, or statistical analysis.
Applicants in second year of HIT program may be considered.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an exhaustive list of all responsibilities and duties. Other duties may be assigned.
Analysis of inpatient, same day surgery, emergency room, Chestnut Ridge inpatient and observation charts to ensure completeness for billing, TJC, Corporate Compliance Plan, HCFA, ACOS, WVUH Bylaws and Rules and Regulations, as well as UHA guidelines, and other accrediting agencies.
Determines the responsible staff, assigns deficiencies to resident and staff physicians for completeness. Standard rate of twelve (12) charts analyzed per hour for inpatient, SDC thirty-five (35) charts analyzed per hour, and OBS twenty-two (22) charts analyzed per hour.
Assigns deficiencies for each deficiency type by physician in Horizon Patient Folder and Merlin.
Analysis of all charts for orders and other printed documentation, identifying deficiency for required signatures, dates and times.
Reviews and assigns undictated Discharge Summaries, Operation Reports, and Catheterization Reports in a timely fashion.
Monitors and generates reports for all deficiency and suspension data, reporting to the Vice President of Medical Staff Affairs, Health Information Management Director and Health Information Management Manager of Technicians in order to comply with TJC Delinquency Rates, Corporate Compliance Plan, HCFA, Hospital Bylaws and Rules and Regulations.
Updates all data as necessary for timely and accurate reporting, for example: completed deficiencies, reassignment of deficiencies, and physician absences when notified.
Produces reports for suspension of physician privileges, unbilled accounts, statistical analysis for TJC, reports for hospital administration, committees, and productivity reports.
Works to ensure the completion of dictated reports and maintenance of accurate undictated lists. Ability to scan the dictation system as needed to verify completion of dictation deficiencies.
Communications with the Medical Staff to ensure accurate and timely completion of all deficient charts and documentation for TJC, Corporate Compliance Plan, ACOS, HCFA, WVUH Bylaws Rules and Regulations, and UHA requirements.
Completion of TJC Record Analysis and other review activities.
Completion of Registry Audits in coordination with Medical Staff Affairs and Nursing Services for certification accreditations.
Completion of abstraction of data for TJC Stroke Certification Accreditation and WVUH Stroke Registry.
Submits abstracted data to Medical Staff Affairs for reporting to TJC and other accrediting agencies as appropriate.
Maintains knowledge base of definitions of strokes, treatable conditions, and the appropriate process of care for stroke diagnosed patients, and knowledge of documentation abstraction skills.
Completion of abstraction of data for WVMI 7th Scope of Work focus areas:
a) Acute Myocardial Infarction (AMI)
b) Congestive Heart Failure (CHF)
d) Surgical Infection Procedures (SIP)
Performs specific system maintenance on the Deficiency Analysis Network in Horizon Patient Folder.
Responsible for compiling and generating reports for medical staff credentialing, statistical information, and compliance for TJC, Corporate Compliance Plan, and HCFA requirements.
Maintains up-to-date definition tables in the deficiency analysis program, updating regularly any changes in medical staff personnel, and departmental changes.
Performs other network system maintenance as necessary and appropriate, including software manual upgrades and testing, modifications, and network problems. Notifies IT Help desk when problems arise for correction.
Perform software and scanner maintenance setup daily by work assignment.
Communicates clearly and effectively both orally and in writing to a variety of customers and end-users.
Maintains patient confidentiality by not revealing and/or discussing patient information with anyone who does not have a legitimate interest in the information.
Observes attorneys, patients, et al, reviewing records as necessary, responding to questions with regard to maintenance of Protected Health Information.
Scans and indexes medical records for optical imaging and routes finished documents to appropriate areas.
Assume primary responsibility for the correction of duplicate patient registrations (duplicate CPI).
Insures proper release of information on all requests for medical information in a timely manner from all WVUH properties in various media formats.
PHYSICAL REQUIREMENTS: 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.
Ability to lift, push or pull 11-20 pounds.
Ability to sit for sustained periods of time.
Endure excessive standing, bending, and stooping.
Have finger dexterity and complete use of hands, arms, and feet.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Moderate level of adversity in working conditions –21-50% of work time.
SKILLS AND ABILITIES:
Knowledge of information system and numerical filing systems.
Good verbal/written and interpersonal skills; basic mathematical skills.
Prior experience with Microsoft window and storage systems.
Good organizational and problem-solving skills.
Be able to withstand stress of a fast-paced environment.
Easily adjusts to change in policies, procedures, schedule, and fluctuation in workload.
Date Reviewed/Revised: April 2016