This role is responsible for accurately uploading and indexing outside records using applicable software, routing documentation to clinicians as appropriate. The specialist will create or select the appropriate patient, encounter, and/or order while assigning the correct document type and description when indexing into the EHR. They will incorporate internal and external clinical documentation from various electronic and paper sources via applicable software work queues, rounding, eDelivery, or importing into the EHR according to HIM procedures, while meeting established benchmarks for quality, accuracy, and productivity. The role requires applying knowledge of medical terminology and nomenclature to accurately identify documentation needs based on patient service areas and level of service provided. The specialist will analyze the content of the medical record for missing documentation and signatures, and assign/edit medical record deficiencies by the responsible provider into the chart management system according to State and Federal regulations. They will provide support and education to clinicians regarding record completion activities, collaborate with Data Integrity or other functional areas to ensure errors are communicated for Chart Correction, and notify appropriate leadership for quality review and privacy investigation. The role ensures clarity, legibility, and position of scanned documents are readable by the end-user or indicates best quality, and serves as a point of contact for record completion support for clinicians and other providers.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED