Primary responsibility of integrity of medical records in accordance with regulatory standards and Agency policies and procedures. Responsible for assimilating and analyzing patient medical records to ensure compliance.
Responsible for and ensures medical records are complete, accurate and meet all compliance standards. Daily duties include record analysis, running various reports, identification of and follow up of deficiencies. Has primary responsibility to oversee and manage workflow related to new admissions/transfers. Workflow duties completed accurately as this function affects billing. Communicates and works with Admissions to establish set up of "Wet Document Folders" and verifies wet document folders are completed and compliant with regulatory/required documents. Finalizes discharge tasks related to wet document folders. Follows up on patient transfer information and communicates with other members of HIM staff to ensure transfers are handled efficiently.
Has primary responsibility to scan documents into the patient's EMR to maintain the integrity of the record. Demonstrates proficiency/accuracy in scanning and scanning function as this affects the record integrity. Has responsibility to review documentation completed on paper by IDG members, identifies missing components and coordinates with appropriate team/dept for further follow up.
Responsibility for pre-billing audits and collaboration with the Accounting Department. Regualtory audits include active and discharged records and includes such items as Consents/Election of Benefits execution, CTI execution, FTF. Consistency and thoroughness is critical as these audits affect claims submitted to Medicare and 3rd party insurances and affect reimbursement. Follows up with Medical Affairs/EMR for missing regulatory items.
Consistently demonstrates compliance with Quality Control Checks (QC) to ensure document is scanned to the appropriate record, the document is aligned properly and the document scanned is legible; also includes QC activites related to workflow, record maintenance, billing tasks etc.
Responsibility for post-billing audits and collaboration with the Accounting Department. Researches discrepancies with death certificates completed by teams which result in denied claims; discrepancies with Certifications processed incorrectly by teams resulting in payment corrections; additional regulatory requests requiring supportive data for Accounting as requested.
Proficient in functions of EMR console and able to troubleshoot issues related to EMR. Competency in other computer systems including Excel, FORTIS, Ultipro and other technology as required. Demonstrates proficiency in running associated reports on a daily basis. Utilizes reports for task completion.
Demonstrates ability to process subpoena requests and other outside requests (including NOK and/or regulatory) for release of record per Florida statutes and HIPAA laws.
Processes death certificates, assists physicians who complete the death certs, answers questions from teams and funeral homes. Maintains spreadsheet for end of month reporting.
Maintains charting audit tools/ computer system database of record deficiencies, delinquencies, and submits reports as required on a daily or monthly basis. Facilitates communication related to identified deficiencies between HIM Dept, teams and other departments (i.e. Admissions, Accounting, Medical Affairs). Participates in improvement activities.
High school graduate or equivalent. Two years medical record experience or similar background preferred. Knowledgeable in medical records, telephone communication, clerical functions, and medical terminology. Appropriate computer background required. Ability to read and interpret documents. Ability to write routine reports and correspondence. Ability to speak before groups of customers or employees. Certification as Registered Health Information Technician (RHIT) preferred.