- Conducts analysis of inpatient, observation, emergency and outpatient charts with 48 hours of discharge/visit.
- Identifies appropriate physician/provider for chart completion of each portion of the medical record.
- Applies appropriate deficiency within the electronic medical record (EMR).
- Assists physicians/providers in completion of the record(s). May respond to questions regarding completion requirements.
- Ensures physician/provider has required understanding of processes and procedures related to compliance.
- Provides daily oversight of transcription services, including running reports checking the accuracy and flow to the EMR, editing patient demographics when necessary, assisting physicians/providers with corrections to transcribed reports, printing and distributing transcribed reports, updating user list (assigning Physician Dictation Number when necessary) within transcription system, and training in the use of the system.
- Provides "uncoded" list to the appropriate Coder.
- Provides completed queries to physicians and appropriate Coder. Follows up on outstanding queries. Scan completed query in to EMR.
- Scans physician notes in to EMR as needed
- Copies, prints and/or faxes pertinent records in response to Request for Release of Record or Continued Care, when requested.
- Copies, prints and/or faxes Face Sheet, discharge date and/or dictations to physician office, when requested.
The successful candidate will possess the following:
- High School Diploma or equivalent
- Five (5) years Medical Records experience, acute care environment preferred
- Working knowledge of the Health Insurance Portability and Accountability Act (HIPAA) and able to effectively applies to all aspects of the position
- Above average organizational skills with the ability to manage multiple tasks
- Demonstrated proficiency with Microsoft Office suite (primarily Word and Excel), with one or more years' entering data
- Experience with Electronic Medical Record (EMR) preferred
- Working understanding of basic office machines including fax, copier and scanner
- Must be able to communicate (speak and understand) English, including complex medical terminology
- Knowledge of medical terminology preferred
- Demonstrated success working in an environment requiring attention to detail