Description
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Summary:
Assures the completion of incomplete medical records within the period as specified by medical staff bylaws. Is able to work cooperatively with medical staff and other healthcare professionals in obtaining documentation to complete medical records. Maintains the delinquent chart count at fewer than 50% of average monthly discharges. Reviews records against completion requirements as documented in the Medical Staff Bylaws or external regulatory agencies.
Responsibilities:
1. Reviews and edits records as completed by physicians to assure that all documentation is complete in accordance with the Medical Staff Bylaws, Rules and Regulations. Retrieves medical records for physician and nursing completion
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a. Maintains an accurate record deficiency system by entering all edits and deletions as needed.
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b. Edits all charts within 24 hours of completion by physician.
2. Maintains Communication:
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Assists medical staff with questions concerning record completion requirements.
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Assists with the education of clinical affiliation students.
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Assists in orienting new employees and new medical staff members.
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Consults with physician office staff as needed.
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a. Readily assists physicians with record completion needs.
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b. Provides accurate and timely information regarding incomplete records.
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c. Good communication skills are used inter and intra departmentally. Promotes harmony and teamwork among coworkers and others.
3. Provides weekly notification to physicians concerning their incomplete record status. Provides notification to the Department Chairman and/or President of the Medical Staff monthly.
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Notifies physicians of their delinquent or deficient charts on a weekly basis. Notifies physicians prior to placing them in suspension status via letter.
4. Other Duties: Assists with other duties as assigned by manager.
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Forwards completed charts to Performance Improvement for medical record review.
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Performs quality control functions to assure accuracy
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Completes other duties as assigned with a positive attitude.
5. Assists with timely billing of records. Maintains a delinquency rate of 50% or less on a monthly basis.
- Audits IDP and assures that billing is complete no later than 30 days post discharge to provide timely reimbursement and data needed by internal and external customers.
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Audits incomplete record file to assure that dictation needed for billing and record completion is put on chart in timely manner.
Other information:
EDUCATION
- High school diploma or equivalent required. Coursework in medical terminology preferred. A.S. in Health Information Technology preferred.
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EXPERIENCE
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Previous experience in a Health Information Services Department required. Previous Meditech experience preferred.
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LICENSURE/REGISTRATION/CERTIFICATION
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OTHER SKILLS AND QUALIFICATIONS
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Developed knowledge of medical terminology. Moderate computer literacy and familiarity with the keyboard. Excel experience preferred. Knowledge of JCAHO, CMS and other external agencies requirement is regarding record completion. Good interpersonal and communication skills required to work with customers and team members in the department and hospital. Flexibility.
Legal Employer: Lenoir Health
Entity: UNC Lenoir Health Care
Organization Unit: Health Info Services
Work Type: Part Time
Standard Hours Per Week: 20.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: LENOIR MEM
Exempt From Overtime: Exempt: No
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
