Responsibilities:

• Reviews the medical record for completeness, timeliness, and accuracy against the requirements of the Medical Staff Bylaws, Medical Staff Rules and Regulations, The Joint Commission (TJC) or other accrediting body’s accreditation standards, the Medicare Conditions of Participation for Hospitals, and other regulatory bodies, upon patient discharge.
• This analysis review will identify whether all required documentation is present and that all entries have been authenticated before the record is filed as complete. Assign identified deficiencies to the responsible provider(s) for timely completion.
• Perform re-analysis, to ensure that deficiencies were completed by the assigned provider and that assigned deficiencies are accurate.
• Perform follow-up with providers related to deficiencies and coding queries to ensure timeliness of responses
• Monitor and report deficiency and query statistics and metrics to the HIM Director.
• Adheres to established hospital standards/policies and system workflow guidelines to add and re-assign accounts to appropriate work queues for processing.
• Ensures integrity of the legal medical record. Verifies correct indexing of the MRN, account number, and/or document type.
• Validates quality and correctness of all scanned images. Identifies documents needing to be re-scanned due to poor image quality and routes those documents to the appropriate work queue for processing.
• Communicates via established protocols to HIM director missing documents and other needs requiring local facility intervention to complete quality integrity review.
• Addresses appropriate questions related to medical record completion from the HIIM Director, Physicians and/or other providers.
• Identifies, designs, and leads process, documentation, and reimbursement improvement initiatives in coordination with HIM Director.
• Meets or exceed established productivity standards.
• Meets or exceeds quality standard of 95% or greater on all audited medical records.
• Assists in maintaining all equipment and supplies required to provide services in an optimal manner.
• Promptly reports issues and trends not complying with facility or corporate policies/standards.
• Assists in cross-training other employees, as necessary.
• Able to work independently
• Performs other duties as assigned.

Position Requirements:

• Associates Degree in Health Information Management or Health Information Technology strongly preferred. Bachelor’s degree a plus.
• RHIT or CPC strongly preferred.
• Minimum three years’ experience in health information management analysis or coding preferred.