Job Description

Major Responsibilities:
Analyzes the content of the medical record for missing documentation and signatures according to State and Federal regulations, such as Det Norski Veritas (DNV) or The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), all Medical Staff Bylaws and organizational policies. Serves as point of contact for record completion support for clinicians and other providers.
Applies knowledge of medical terminology and nomenclature to accurately identify documentation needs based on patient service areas and level of service provided. Assigns, edits, and tracks medical record deficiencies by responsible provider into chart management system accurately and timely following established policies and procedures. Uses strong communication and critical thinking skills to investigate and troubleshoot.
Provides support and education to clinicians and providers regarding record completion activities. Verifies accuracy of physician deficiency and suspension status in the chart management system. Supports activities for accurate reporting and of physician delinquencies for the suspension process. Accurately sends notification and/or suspension notifications to clinicians and physician leadership.
Supports Revenue Cycle by analyzing and identifying missing documentation elements needed to support physician and hospital coding. Identify problems or issues with front end workflow. Collaborates with Clinical Informatics, Revenue Cycle Trainers, and various department leadership to identify system issues, and to provide educational opportunities to clinicians, providers and team members as needed.
Receives, collects, sorts, prepares and scans internal and external clinical documentation into the EHR according to Health Information Management (HIM) procedures. Sorts and measures incoming and remaining scanning to accurately track volumes and turn-around times in the system-wide database.
Utilizes medical terminology to accurately classify clinical documentation for all tests, treatments, procedures, and other services. Creates or selects the appropriate patient, encounter, and/or order while assigning the correct document type and description when scanning/importing into the EHR.
Performs quality assurance checks of scanned images to verify correct document type/patient/encounter and, if applicable, order. Uses critical thinking and problem solving to make corrections and/or edits according to Health Information Management policy. Verifies the electronic document against the paper document to ensure correctness. Confirms that patient records are scanned correctly to the patient, encounter, document type or order in a timely manner. Ensures clarity, legibility and position of the scanned documents is readable by the end user or indicates best quality. Appropriately forwards completed work to the next step of quality control to ensure integrity, completeness and legibility of scanned patient records. Provides timely, constructive feedback and re-training where appropriate for quality control audits.
Accurately abstracts patient information discretely into the EHR to ensure clinical notifications and alerts are present for all clinical team members appropriately. Analyzes documents for validity and generates letters to patients as appropriate.
Completes timely error correction; including deleting images and re-scanning and re-indexing/appending documents appropriately. Notifies appropriate leadership for quality review and privacy investigation.
Assists patients, visitors and internal and external customers as appropriate in person or via telephone in a prompt and courteous manner. Operates all office equipment, performs daily routine maintenance of equipment and reports any equipment malfunction or poor image quality to the appropriate personnel. Receives and processes continuing care requests in accordance with AAH release of information policies and procedures and any applicable legal regulations. Properly manages the record destruction of all qualified records according to retention and policy.

Licensure, Registration, and/or Certification Required:
None Required.

Education Required:
High School Graduate.

Experience Required:
Typically requires 1 year of experience in Health Information Services or related field, or experience as a Health Unit Coordinator or Medical Assistant.

Knowledge, Skills & Abilities Required:
Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, OnBase, Microsoft Office and legacy archives.
High attention to detail and accuracy with frequent interruptions.
Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints.
Ability to work independently and make decisions with minimal supervision while maintaining quality and productivity standards.
Strong customer service, interpersonal and communication service skills.
Works collaboratively in a diverse team environment with openness and respect to learn, create and problem solve.
Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success.
Ability to adapt to a fast-paced environment and transition to switching tasks without issue while maintaining quality and accuracy.
Ability to safeguard protected health information (PHI) and possesses basic knowledge of HIPAA.

Physical Requirements and Working Conditions:
Ability to proficiently operate all equipment necessary to do the job: fax, multi-phone line, copy machine, etc.
Must be able to sit, stand, walk to perform rounds in time allotted, squat, twist/rotate, bend and reach for prolonged periods of time in order to complete required word processing, filing, photocopying, and distribution of materials and other related functions.
Requires team member to walk a moderate/significant distance throughout medical center to retrieve records. May require the ability to push/pull a records cart.
Ability to perform repetitive functions and hand movements in a normal office environment.
Ability to lift, push and pull items weighing up to 20 lbs.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.