Facility
Cape Fear Valley Medical Center
Location
Fayetteville, North Carolina
Department
Health Information Management
Job Family
Clerical
Work Shift
Days (United States of America)
Summary
Performs extensive reviews of patient records to confirm that documentation requirements of accrediting and other regulatory agencies are met. Independently coordinates, monitors and follows-up timely on chart completion issues and physician complaints in this regard. Releases patient records and information consistent with established guidelines. Based on demonstrated knowledge, experience and senior status also serves as point of contact for chart completion issues and training of new staff. Also, consistently assists with quality, integrity and related chart reviews.
This is an ONSITE POSITION.
MAJOR JOB FUNCTIONS:
The following is a summary of the major essential functions of the job. The incumbent may perform other duties, both major and minor, that are not mentioned below; and specific functions may change from time to time.
- Communicates and follows-up with physicians and other health care providers regarding medical record completion as needed to coordinate chart completion in a timely and cooperative manner. Carries out duties in this regard as outlined in the Delinquent Medical Record Policy and other related procedures.
- Consistently validates practitioners’ deficiency lists, assuring charts listed in the pending suspension workqueue were correctly assigned by researching other encounters or contacting physician offices timely to expedite record completion.
- Timely notifies physicians of pending records that need completion, identifying those physicians who will be suspended. Prepares the physician suspension list for the Health Information Management Operations Manager verifying its accuracy prior to submission and distribution to Administration, Medical Staff Members and designated departments.
- Assists in expediting the completion of priority records needed for Release of Information, DNFB, and/or other high-risk cases. Communicates directly with physicians and/or their office staff as needed to obtain required chart documentation within specified time frames.
- Orient new physicians to HIM chart completion processes. Assist physicians with the electronic medical record completion processes.
- Proficient in all chart completion functions.
- Applies knowledge of TJC standards, Medical Staff Rules & Regulations, general regulatory requirements and health system policies and procedures as needed to make accurate chart completion assignments.
QUALIFICATIONS:
The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:
EDUCATION AND FORMAL TRAINING:
- High school diploma or equivalent required
- Experience and training in all areas of acute care, health information management processing required
- RHIT, RHIA, or other equivalent credentials preferred
WORK EXPERIENCE:
- One year of experience in Health Information Management with experience in chart analysis and regulatory knowledge of chart completion
- Specific experience in the processing of electronic medical records is preferred
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:
- Knowledge of general medical record format and content
- Should demonstrate the ability to type 40-45 wpm accurately or demonstrate sufficient keyboard familiarity to perform job functions
- Must have intermediate experience in the use of computers in a Windows environment
- Basic understanding of medical terminology
- Knowledge of Joint Commission and other regulatory agency chart documentation requirements
- Good organizational skills with the ability to manage multiple priorities and make good independent decisions
- Attention to detail and quality to include strong recall and recognition skills
- Ability to work in a team environment as well as work alone when necessary
- Ability to work under pressure with ongoing time constraints
- Initiative and ability to provide excellent customer service to enhance patient care delivery by assuring timely and accurate access to medical records
- Excellent written and oral communication skills
PHYSICAL REQUIREMENTS:
- Extended periods of sitting, with some instances of reaching, bending, stooping, pushing, and pulling all requiring use of proper body mechanics
- Ability to work productively in a high volume, high stress work environment
- Visual acuity for reading and processing charts/information
- Dexterity of upper extremities and fingers, as well as mental dexterity for accurately sorting medical record documents
- Light to moderate lifting of plus or minus 25 pounds of boxes containing medical record documents
Required Licenses and Certifications
Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity