HIM Analysis Tech Medical Records

Mount Sinai Medical Center•Miami Beach, FL

5d•Onsite

About The Position

This is an entry-level Analyst role in HIM, responsible for analyzing and managing medical record deficiencies to ensure timely, accurate chart completion in compliance with Joint Commission standards. The role requires working knowledge of medical record content, physician documentation workflows, and EPIC/One Content, with the ability to assign, reassign, and audit deficiencies accurately. Candidates must have at least one year of hospital HIM or medical records experience, strong written and verbal communication skills, attention to detail, and the ability to maintain strict patient confidentiality. A high school diploma is required, with additional technical training and quality analysis experience being preferred.

Requirements

At least one year of hospital HIM or medical records experience.
Strong written and verbal communication skills.
Attention to detail.
Ability to maintain strict patient confidentiality.
High school diploma required.
Working knowledge of medical record content.
Working knowledge of physician documentation workflows.
Working knowledge of EPIC/One Content.
Ability to assign, reassign, and audit deficiencies accurately.

Nice To Haves

Additional technical training.
Quality analysis experience.

Responsibilities

Receives and reviews each discharged patient's record for incomplete or missing items (deficiencies or missing text) and identifies the responsible practitioner for each of these items.
Assigns deficiencies to physician's according to procedures accurately.
Monitors reanalysis queue (physician decline queue) daily and reassigns deficiencies when appropriate.
Performs reanalysis process within quality standard.
Call/email and fax physicians to encourage compliance with chart completion.
Verifies chart completion and monitors the reanalysis queue to ensure all records are completed appropriately.
Uses initiative and creativity to encourage physician compliance with chart completion policies.
Answer any questions or concerns from physicians, mid-levels and/or residents regarding deficiencies in EPIC/One Content or direct these individuals to the appropriate person for clarification.
Review Verification and Decline queues daily to update documentation to meet Joint Commission.
Knowledgeable of medical record content.
Reviews assigned work queue's daily and ensures timely turnaround within required time frames when processing all assignments in the queues.
Knowledgeable of Joint Commission requirements for chart completion.
Ensures all reports are linked.
Knowledge of the Medical Staff roster to maintain accuracy of assigning deficiencies.
Communicates clearly and effectively both orally and in writing.
Maintains patient confidentiality by revealing and or discussing patient information with anyone who does not have legitimate interest in the information.
Ensures that all indexed documents are of an acceptable quality and that documents are indexed to the correct document types and patient encounters.
Correctly inserts pages/documents when and where appropriate.
Efficient in ADI (Adjusting Document Indexing).
Complete monthly forms audit to ensure physician compliance with TJC standards.
Completes other duties as assigned by His/Her department manager.