Responsible for record processing functions to include record analysis of one or more record types - electronic, digital and paper; identifying deficiencies in documentation in accordance with Medical Staff Bylaws, Rules and Regulations, accrediting organization standards and other regulatory requirements, and hospital policy. Ensures that all designated record set (DRS) paper documents are accounted for and scanned into the electronic health record (EHR) under the proper form identification and in the proper EHR location within the prescribed turnaround time. Uses critical thinking to assist in identifying and troubleshooting EHR functional issues and missing or incorrect documents/documentation. Makes suggestions for, and participates in, process analysis and redesign. Establishes working relationships with multiple departments. This is an entry level position.
The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below; and specific functions may change from time to time.
Analyzes medical records to ensure the presence of reports appropriate and required for that visit type.
Analyzes documentation for the presence of required signatures, co-signatures and signature date/time.
Assigns in Meditech deficiencies to physicians by deficiency type.
Monitors record completion and as deficiencies are completed, removes deficiencies from Meditech.
Communicates to physicians outstanding deficiencies; assists physicians with record completion questions and issues.
Ensures daily front-end accountability of paper records of inpatient discharges and outpatient visits. Performs immediate follow-up for any unaccounted-for patient record.
Preps records for scanning; performs quality control (QC) to ensure documentation is of good quality and each record contains the required documents.
Scans records into the EHR through the Meditech scanning and archiving system.
Performs QC functions on completed records.
Reports to HIM leadership any process issues identified.
Follows all departmental and hospital policies and procedures.
Performs other job-related duties as assigned.
High school diploma or GED.
Associates degree in Health Information Management preferred.
One year experience in health information management or equivalent experience.
Knowledge, skills and abilities required:
Basic knowledge of the medical record and its contents.
Working knowledge of the Medical Staff Bylaws Rules and Regulations, and medical record policies.
General knowledge of computers, including the Meditech EHR.
Knowledge of medical terminology.
Analytical/organizational skills and attention to detail.
Strong verbal and written communication skills.
Interpersonal skills. Ability to establish a good rapport and effectively communicate with the public, hospital and medical staff.
Basic troubleshooting and problem resolution skills.
Critical thinking skills.
Troubleshooting basic computer, scanner, and other office equipment related problems.
Concentrating and maintaining accuracy in spite of frequent interruptions.
Manual dexterity to handle documents, type and maneuver within the EMR.
Employment Type (feed only)
Full Time Temporary (NO BENEFITS)