Health Info Tech III Concurrent Analysis - Medical Records - Full Time / Days Req# 2063869704

Brief Description

Under the supervision of the Director of Health Information Services and under the direction of the Service Coordinator will perform a variety of duties related to Chart Review and Chart Deficiency Analysis. This position will maintain daily workflow, ensuring timely processing of record review, analysis and data entry with a high level of quality.

Duties and Responsibilities:

• Concurrent Chart Review and Analysis of Records
• Reviews records of current Inpatient, Observation and Outpatient in a Bed patients for presence of History and Physical, Operative Report or Procedure Report as indicated.
• Researches and enters patient data into various systems as defined by procedure.
• Notifies providers of the missing documentation.
• Chart Reviews and Chart Deficiency Analysis for Emergency Department, Outpatient in a Bed, Observation and Inpatient patients.
• Reviews each discharged patient’s record for incomplete or missing items and identifies the responsible provider for each of these items.
• Enters provider deficiency data in the chart completion system or other system for regulatory reviews.
• Moves documents to appropriate document type as defined by procedure.
• Scans reference documents as appropriate.
• Monitors chart completion queues and other queues as assigned to ensure records are completed appropriately.
• Verifies provider dictation in dictation system if provider has documented dictation complete.
• Routes records for clinical pertinence review as defined by procedure.
• Routes unidentified, incorrectly positioned, and poor-quality documents to the problem queue.
• Chart Completion
• Communicates regularly with providers regarding incomplete charts, queries, amendments, and responds accurately to questions regarding chart completion requirements.
• Assist providers on the use of the document imaging system for chart completion.
• Generates provider notification letters timely and according to policy.
• Correctly identifies providers who are eligible for suspension and communicates appropriately with the physician regarding same.
• Processes suspension and reinstatement notices ensuring all hospital departments are notified timely.
• Monitors provider chart completion using document imaging system reports.
• Runs incomplete chart reports as defined by procedure.
• Uses initiative and creativity to encourage provider compliance with chart completion policies.
• Release of Information
• Copies, prints, or faxes pertinent records in response to requests for release of records or continued care.
• Documents or communicates requests or releases of records in appropriate system or to appropriate staff.
• Protects the confidentiality of primary and secondary health records and releases information as mandated by law, professional standards, and the hospital's policies.
• Other Duties
• Assists hospital staff, medical staff, public, and patients.
• Plans, organizes, prioritizes, and coordinates work to achieve functional area goals and maximum productivity and efficiency on a day-to-day basis.
• Answers telephones consistent with Service Excellence standards, addresses and/or routes calls appropriately and in a timely manner.
• Researches and enters patient data into various systems as defined by procedure.
• Technically evaluates, assembles, and processes documents in preparation for the scanning process while ensuring correct patient identification on each page of record.
• Performs quality control and indexing processes to ensure all documents are assigned the appropriate document name and all documents are scanned into the correct patient folder with the highest level of quality.
• Protects the confidentiality of primary and secondary health records and releases information as mandated by law, professional standards, and the hospital's policies.
  
  

Non-Essential Duties:

Accepts and carries out other miscellaneous duties and responsibilities within skillset and abilities as required for maintaining the services provided by Medical Records.

Knowledge, Skills and Abilities:

Knowledge

• Knowledge of Microsoft Office applications.
• Knowledge of department policies, practices and operations.
  
  

Skills

• Perform data entry accurately with use of a keyboard and mouse.
• Perform duties using computers and equipment required for printing or scanning of documents
• Effective oral and written communication skills.
• Detail oriented and organized.
  
  

Abilities

• Ability to learn the advanced aspects of the various indexes, storage, tracking, and retrieval systems.
• Ability to retrieve, reproduce, deliver, track, and file records using various equipment and systems in the facility and offsite.
• Ability to review records and verify patient information.
  
  

AVMC Values: All AVMC employees will effectively demonstrate these values:

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.
  
  

Education and Experience:

Education

• High school graduate or GED equivalent.
  
  

Experience

• One-year prior experience working in an acute care hospital medical record/other business-related department or provider office required.
• Prior experience with provider chart completion preferred
• Experience interacting with providers required.
  
  

Required Licensure and/or Certifications:

• None
  
  

AVMC Conduct/Compliance Expectations:

• Ability to adhere with AVMC Attendance and Punctuality Policy.
• Ability to adhere with AVMC Leaves of Absence Policy.
• Ability to adhere with AVMC Paid Time Off (PTO) Policy.
• Ability to adhere to the department dress code.
• Ability to organize work and establish priorities.
• Ability to expand on own initiative in performance of duties.
• Skill and ability to follow the telephone etiquette/standards.
• Ability to function effectively under pressure and meet time parameters.
• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff.
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC.
• Ability to maintain the confidentiality of patient, hospital and department information.
• Ability to adhere to safety rules and regulations.
• Safely and effectively uses all equipment necessary to carry out duties.
  
  

Ability to interpret and function under hospital and department policies and procedures.

• Conforms with required and appropriate accreditation and regulatory requirements.
• Conforms with and supports hospital quality assurance and improvement guidelines.
• Ability to participate effectively in department and hospital staff education.
• Display a willingness to work as a team player.
• Ability to give and support the highest level of patient/customer satisfaction at all times.
• Supports and adheres to the values and mission statement established by the AVMC Board of Directors.
• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
• Ability to follow the Code of Conduct.
  
  

Physical Requirements and Working Conditions:

• Work is usually performed in a normal office environment and may require long periods in sedentary position performing one function.
• Trips within the facility and to onsite storage areas will be required to retrieve or deliver records.
• Frequent use of scanner, keyboard and video display terminal.
  
  

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

NOTE: THE ABOVE STATEMENTS ARE INTENDED TO DESCRIBE THE GENERAL NATURE AND LEVEL OF WORK PERFORMED BY PEOPLE ASSIGNED TO THIS JOB. THIS DOCUMENT IS NOT INTENDED TO BE AN EXHAUSTIVE LIST OF ALL RESPONSIBILITIES, SKILLS, AND WORKING CONDITIONS FOR THE PERSONNEL SO CLASSIFIED.

Requirements

Education and Experience:

Education

• High school graduate or GED equivalent.
  
  

Experience

• One-year prior experience working in an acute care hospital medical record/other business-related department or provider office required.
• Prior experience with provider chart completion preferred
• Experience interacting with providers required.
  
  

Required Licensure and/or Certifications:

• None