CLINICAL DOCUMENTATION ANALYST Full Time Days

BASIC PURPOSE OF THE JOB

Reviews accuracy and completeness of medical records to assure that all patient documents are maintained in accordance with hospital and regulatory guidelines. Works with clinical staff/physicians to obtain missing information for patient medical records.

REPORTS TO

• Health Information Manager

JOB REQUIREMENTS

Supervisory Responsibilities: No

Minimum Education: Associates Degree

Degree: Health Information Management or related field

License/Certification Required: Registered Health Information Technician (Preffered)/Registered Health Information Administrator

Minimum Work Experience: 2-3 years experience in Health Information Management preferred

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Proficient in the use of computers with knowledge of Microsoft Word and Outlook
• Ability to maneuver through several computer programs
• Ability to prioritize work
• Knowledge of medical terminology
• Strong organizational and time management skills
• Excellent interpersonal and customer service skills
• Ability to interact with persons of varying backgrounds and education levels

DUTIES AND RESPONSIBILITIES

• Analyzes Inpatient, Observation, and Same Day Surgery records to assure their timely completion and accuracy.
• Maintains analysis back log on Inpatient, Observation, and Same Day Surgery records, on average, within 5-7 days of discharge.
• Accurately identifies, assigns and updates all deficiencies for providers.
• Performs quality assurance (QA) on scanned records for Inpatient, Observation, Same Day Surgery patients.
• Performs rescans of completed medical records within 3 days of completion.
• Audits discharge analysis work list bi-monthly to assure that analysis has been performed on every Inpatient, Observation, Same Day Surgery patient medical record.
• Reviews completed dictations morning and afternoon; assigns and removes dictation deficiencies accurately and timely in HIM software.
• Completes the electronic signature rejection report daily.
• Sends written notifications for any impending delinquent Deficiencies to medical staff department heads, and Chief of Staff prior to creating the No Admit/No Clinical Privileges List.
• Creates the No Admit/No Clinical Privileges List on the first of the month according to regulatory and hospital guidelines; monitors and updates the No Admit/No Clinical Privileges list daily.
• Assists physicians/practitioners with completion of medical records to include taking/picking up incomplete records to and from the surgery lounge.
• Assists co-workers as needed in a courteous and professional manner.
• Utilizes hospital resources and time respectfully and accountably.

PHYSICAL REQUIREMENTS

• Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
• Medium lifting, pushing and pulling is required for 20-50 lbs occasionally, 10-20 pounds frequently and 10 lbs constantly to move objects. Sudden emergency situations have the potential for exposure for lifting or moving of up to 100 lbs. Frequent bending, walking, sitting, squatting, reaching, and standing are required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference everyday.