Address
Form of workBASIC PURPOSE OF THE JOB
To provide a clinically based review of patient medical records through a team-oriented and concurrent interaction approach with physicians, coders and other members of healthcare staff to ensure the appropriate clinical severity is captured for the level of service rendered to the patient.
REPORTS TO
- Director, Health Information Management
JOB REQUIREMENTS
Supervisory Responsibilities: No
Minimum Education: Associates or Bachelor's Degree required.
Degree: Degree in Nursing
License/Certification Required: No
Minimum Work Experience: 2 years experience in Health Information Management field preferred
REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES
- Excellent organizational and time management skills.
- Very detail-oriented, advanced analytical and problem solving skills.
- Ability to manage multiple tasks simultaneously.
- Detailed working knowledge of the health record and chart organization.
- Detailed knowledge of documentation and privacy regulations.
- Proficient in word processing and computer applications.
- Ability to meet time constraints and deadlines.
- Excellent customer service skills and comfortable working with physicians as well as other hospital practitioners and staff members.
DUTIES AND RESPONSIBILITIES
- Provides concurrent review of the CLINICAL DOCUMENTATION in the medical record to assist in properly reflecting the patient acuity and severity of illness; review the medical record with a clinical lens to identify any missing or understated diagnoses.
- Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan.
- Performs a thorough chart review to assist in determining the appropriate principal diagnosis of the patient.
- Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet.
- Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.
- Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the appropriate acuity of the patient, severity of illness, and risk of mortality to support proper DRG assignment and coded data.
- Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.
- Maintains flexibility and prioritizes daily responsibilities.
- Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
- Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
- Utilizes hospital resources and time respectfully and accountably.
- Willingly accepts any other assignment that may be requested.
PHYSICAL REQUIREMENTS
- Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
- Light lifting, pushing and pulling is required for 1-20 lbs occasionally and frequent moving of objects of less than 10 lbs is required. Frequent sitting with some walking, standing, squatting, bending, and reaching is required. Keyboard/computer use and/or repetitive motions may be required.
Come work where you can make a difference everyday.
