Responsibilities:
- Compiles statistical data, such as admissions, discharges, deaths, births, and types of treatment given.
- Abstracts information for the medical record.
- Analyzes records in accordance with the HIM analysis procedure with a minimum of 95% accuracy.
- Performs quantity and quality checks on scanned medical record information as part of Quality Control (QC) function.
- Accurately completes daily, weekly, monthly, and quarterly reports
- Ensure all scanned documents are scanned in chronological order
- Ensure patient identifiers are present on all scanned pages
- Ensure that all scanned documents belong to the same patient with the same date of service
- Verify that images are correct and legible. Review each electronic image and compare with the hard copy to confirm the image quality, appropriate order and appropriate rotation.
- Conducts quality assurance and quality improvement on scanned/indexed documents
- Enters, edits and tracks medical record deficiencies in chart management system. Effectively communicates with physicians to resolve and manage physician deficiencies.
- Reviews medical records edited by physicians and updates the HIM system as needed.
- Compiles, updates, and reports physician record completion statistics and physician notification letters. Prepares physician list and handles the suspension process.
- Produces and distributes delinquency notification/suspension letters, verifies accuracy of deficiency information, reports physician record completion statistics and updates.
- Monitors records submitted for reanalysis to ensure accurate completion of records. Ensures completion of existing file deficiencies and verifies accuracy of information submitted
- Serves as a liaison to physicians regarding issues related to incomplete records and documentation to ensure adherence to Joint Commission standards and compliance requirements.
- Facilitates chart availability and readiness for coding.
- Assures patient’s records have been received upon patient discharge.
- Facilitate the completion of birth certificates and ensure they are filed with the correct registrar within the state requirements.
- Assists patients with patient portal questions and password re-sets.
- Assists visitors and physicians, and answers phone as needed.
- Monitors the transcription system if needed.
- Coordinates the ROI function if needed.
- Responsible for the integrity and quality of the documents that are scanned into the document management system, tracking of unidentified documents, re-scanning documents, assigning document types to unknown documents.
- Ensures that all discharged records are received from the units for document imaging. Performs follow up of missing documents and verification that all charts have been received and scanned.
- Continuously meets all turnaround times as requested and per Departmental policy.
- Responsible for analysis of patient’s records for needed documentation by the physician as well as for the physician suspension process and record deficiency tracking.
- Operates computer to enter and retrieve data.
- Accepts subpoenas after verifying their validity.
- Responsible for accurately scanning authorizations, subpoenas, request into the system.
- Ensures all documentation is accurate and in the appropriate format to meet Joint Commission accreditation standards.
- Reviews the integrity of the Master Patient Index (MPI) to provide an accurate database, ensure each patient and number is uniquely and correctly identified.
- Combines patient records that are duplicated; pull and combine chart to merge the physical record.
- Handles all incoming calls regarding registration issues due to duplicate or incorrect number assignment.
- Maintains log of activities. Continuously meets all turnaround times as requested.
- Meets or exceeds productivity standards.
- Responsible for cross-training peers.
- Assists the HIM Department and various work units during times of staff shortage or high volumes –
- Responsible for other duties and special projects as assigned by management.
- Maintains strict physician and patient confidentiality
- Follows all federal, state, industry, and hospital guidelines for release of information.
- Supports Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by in-service attendance and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient information.
- Reviews materials, complete all required client policy training documents and passes required tests.
SKILLS:
- Demonstrates a positive attitude and the ability to communicate effectively with customers, staff, management and peers.
- Fosters respect for patient privacy by maintaining confidentiality in all phases of work. Prioritizes daily work responsibilities and manages time well in order to consistently meet deadlines.
- Demonstrates the ability to work under pressure and comply with high productivity standards and expectations.
- Adapts to change easily and is able to work in an environment of continuous change. Demonstrates initiative and willingness to assist the department as needed.
- Ability to work effectively in a team environment.
- Performs other related duties as assigned or requested
QUALIFICATIONS:
- High school graduate or GED required.
- Minimum one year of previous HIM or equivalent experience or education required. Proficiency with HIM computer systems required. Previous office clerical or administrative experience preferred. Knowledge of medical terminology.
- Strong computer knowledge including MS Office (Outlook, Word, Excel). RHIT/RHIA Certification is a plus.
