Medical Record Review Auditor - Health Information Services

Job Requirements

Position Summary: To be fully engaged in providing Uncompromised Safety, Superior Quality, Memorable Patient/Customer Experiences, and Financial Stewardship by:

Primary Accountabilities:

Quality/No Harm:

• Demonstrates competence in the following clinical applications to include: SCM, ED Manager, eMon, SIS, HPF/QCI, RRA, Laserfiche and Midas. Proficiently navigates through the above listed clinical applications in order to:
• Identify patient using two patient identifiers and able to locate appropriate chart based on that information.
• Verify the accuracy of demographic area.
• Proficiently navigates through Microsoft Office applications to include:
  Word, Excel, and Power Point.
• Responsible for confidentiality, security, and integrity of all personal health information for all patients
• Writes scanned and indexed batches to the appropriate queue according to departmental policy and procedure at least 98% of the time.
• Monthly, ongoing chart reviews (Clinical Pertinence, Medical, Surgical and Critical Test Results) are completed in a timely manner 100% of the time. Results are tabulated and formatted in a consistent manner for presentation on a timely basis. Reports are available for review one week prior to the date of presentation. These reviews include medical record review committee audits as well as audits related to Patient Safety, Quality Improvement, National Patient Safety Goals, etc.
• Items which fall out on audits are copied and forwarded to a designated person responsible for follow up with the appropriate parties at each facility.
• Maintain and coordinate review forms for chart reviews across all facilities and chairs/co-chairs Medical Record Review Committee.
• Assist in validation and monitoring of quality related to content and completeness of legal health record.
• Adequately prepares for meeting(s), sending or emailing notices and preparing the agenda. Attends meeting on time to distribute packets to members. Completes original minutes for committee binder.
• Responsible for attending and reporting results at assigned facilities and assisting in creating action plans to improve compliance and documentation.
• Participation in Joint Commission Readiness meetings, chart reviews and assist as necessary to surveys.
• Complete additional focused reviews as assigned by HIM Manager.
• Responsible for correcting incorrect chart documentation to include wrong patient, wrong accounts, and other discrepancies. Performs Adjust Document Index function to include correctly inserting, splitting, moving, and appending pages/documents when and where appropriate at least 98% of the time.
• Charts are accurately analyzed according to Joint Commission requirements and Medical Staff Bylaws and Rules and Regulations, correctly identifying missing elements and assigning deficiencies to the correct physician at least 98% of the time.

Customer Experience:

• Provide patient information to appropriate requesters in a timely and efficient manner.
• Understands the confidentiality of patient information and proper dissemination of this information. Adheres to all Health First policies and procedures in regards to protected health information. Consults with management to clarify any concerns.
• Coordinates on-site medical record audit requests for external and internal requestors. Audits are available for review to authorized individuals at the time and date agreed upon when the request was submitted.
• Provides assistance with any questions the physicians may have about their deficiencies and how to access assignments/complete deficiencies through the physician portal or directs the physician to the…