Medical Record Review Auditor - Health Information Services

Health First Careers • Rockledge, FL

13d • Onsite

About The Position

The Medical Record Review Auditor - Health Information Services role at Health First is responsible for maintaining accurate and complete medical records, ensuring the confidentiality, security, and integrity of patient data. This position involves abstracting and compiling clinical data for quality improvement, benchmarking, trend identification, and action plan development. The goal is to ensure timely and complete use of data and information without compromising security and confidentiality. Responsibilities may vary within the department.

Requirements

• RHIA or RHIT or eligible within 24 months
• 1-3 years of previous health information management experience preferred
• Excellent computer skills and proficiency with Microsoft Office applications
• Understanding of Joint Commission standards, State Regulations, HIPAA, CMS and Medical staff rules and regulations requirements preferred
• Visual acuity to include viewing PC monitor for extended amount of time.
• Ability to enter data and work with medical records using hand/wrist dexterity.
• Ability to sit at a computer for extended periods of time.
• Ability to walk or stand for extended periods of time.
• Ability to bend and stoop.
• Ability to read and comprehend instructions, correspondence, memos, and electronic mail
• Excellent computer and skills with the ability to enter and retrieve data from electronic systems
• Strong written and verbal communication skills for professional interaction
• Must be detail and accuracy oriented.
• Ability to work independently and maintain focus on the scope of work assigned.
• Must be self-sufficient, not needing to rely on others to complete a job.
• Ability to coordinate and use logical reasoning to prioritize tasks and manage multiple tasks simultaneously
• Initiative – independently takes prompt proactive steps toward problem resolution.
• Analytical skills – effective evaluation, synthesis and use of information gathered.
• Must be able to work under potentially stressful situations with time constraints
• Ability to use critical thinking and problem solving skills to carry out all job functions and responsibilities
• Emotional intelligence – recognize and understand emotions and use this awareness to successfully manage yourself and your relationships with others.

Nice To Haves

• 1-3 years of previous health information management experience
• Understanding of Joint Commission standards, State Regulations, HIPAA, CMS and Medical staff rules and regulations requirements

Responsibilities

• Maintain accurate and complete medical records for each patient treated at Health First.
• Assure the confidentiality, security, and integrity of data and information.
• Abstract and compile clinical data in a meaningful manner for quality improvement, benchmarking, identification of trends, and development of action plans.
• Identify patients using two patient identifiers and locate appropriate charts.
• Verify the accuracy of demographic information.
• Write scanned and indexed batches to the appropriate queue according to departmental policy and procedure at least 98% of the time.
• Complete monthly, ongoing chart reviews (Clinical Pertinence, Medical, Surgical and Critical Test Results) in a timely manner 100% of the time.
• Tabulate and format results for presentation on a timely basis, with reports available one week prior to the date of presentation.
• Forward audit items to a designated person for follow-up.
• Maintain and coordinate review forms for chart reviews across all facilities and chair/co-chair the Medical Record Review Committee.
• Assist in validation and monitoring of quality related to content and completeness of the legal health record.
• Prepare for meetings by sending notices and preparing agendas, attend meetings on time, distribute packets, and complete original minutes for the committee binder.
• Attend and report results at assigned facilities and assist in creating action plans to improve compliance and documentation.
• Participate in Joint Commission Readiness meetings, chart reviews, and assist with surveys as necessary.
• Complete additional focused reviews as assigned by the HIM Manager.
• Correct incorrect chart documentation, including wrong patient, wrong accounts, and other discrepancies.
• Perform Adjust Document Index function to correctly insert, split, move, and append pages/documents at least 98% of the time.
• Accurately analyze charts 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.
• Provide patient information to appropriate requesters in a timely and efficient manner.
• Coordinate on-site medical record audit requests for external and internal requestors.
• Provide assistance to physicians regarding deficiencies and how to access assignments/complete deficiencies through the physician portal or direct them to the appropriate person.
• Work closely with the Quality Department regarding documentation compliance and record content.
• Take initiative to take on additional assignments or changes in scheduling.
• Assess the need to contribute to analysis or other areas that could be falling behind departmental targets.
• Ensure that all external audits are appropriately followed up and completed after approval of the HIM Manager 100% of the time.
• Understand and support the processing of reports according to department turn-around-time goals.

Benefits

• Diversity and inclusion are essential for our continued growth and evolution.
• Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates.
• Different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results.
• It fuels our innovation and connects us closer to our associates, customers, and the communities we serve.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: No Education Listed