PURPOSE OF POSITION: Review, research, and resolve problems and errors concerning: patient identifiers, data integrity of the electronic or paper medical record, and CCHMC source systems. Ensure a complete, accurate, and timely record that supports a variety of initiatives such as patient safety, continuity of patient care, quality and performance measurements, billing, administrative uses and standards set by accreditation & regulatory agencies.
Identify data requirements and perform structured/random quality audits across multiple software applications to validate accuracy of data/data sets, interfaces, and work queues. Verifies that medical records are disclosed appropriately, destroyed per destruction policies, and that transcribed and imaged documents meet quality standards, data is collected according to data definitions and guidelines. Utilize knowledge of electronic health record (EHR) associated with the collection and distribution of clinical data to participate in data integrity audits, manage revisions to the electronic medical record, and correcting critical data elements identified as incorrectly documented and/or scanned. Coordinate and manage medical record form development
Track various data errors, and complete analysis to recommend correction. Design and prepare statistical, trending, and performance improvement reports for management related to issues such as duplicate medical record numbers, and imaging quality, etc. Identify and inform HIM department management of incorrect data process or workflow issues and take initiative to recommend corrective action as appropriate. Assist in the development and coordination of the performance improvement (PI) program for health information management, including standards and requirements consistent with those of CMS, Joint Commission, the Office of Civil Rights, State/Federal Law and other accreditation and regulatory agencies.
Promote positive internal and external customer relations through prompt and courteous service. Examples include communicating with transcription vendors, off-site storage vendors, assisting requestors to obtain medical information, changing patient names, assisting in dictation issues, documentation issues, and working directly with customers (patients, families, third party payers and auditors) to help them understand documentation practices at CCHMC.
Assist in the testing/implementation of new systems/system improvements. Assist with problem resolution regarding issues such as duplicate/merged medical records, name changes, off-site storage of medical records, quality review of imaged documents, setting up accounts in the document imaging system, interface issues and documentation errors, and disclosure of protected health information issues. Utilize existing system tools/reports and learn new tools for monitoring purposes.
·Serve as a Resource
Train and coach newly hired staff using basic presentation skills. Serve as a liaison between management and HIM staff for communication and process improvement activities. Continuously monitor training needs and ensure that training or re-training is provided as needed. Participate in project management for performance improvement teams, departmental planning sessions, as well as other organizational meetings as requested and needed. Participate in multiple projects simultaneously as needed.
Skills & Competencies
·Workflow - Basic
Basic understanding of workflow
Working cooperatively with others to achieve group goals; proactively adjusting one's style and efforts to complement those of others on the team; being pleasant, agreeable, and easy to work with; valuing group success as much or more than individual success
Understanding and showing respect and appreciation for the uniqueness of all individuals; leveraging differences in others' perspectives and ideas; appreciating cultural differences and adjusting one's approach to successfully integrate with others who are different from oneself
Proficiency in basic computer applications such as Microsoft Office (Word, Excel, Access), e-mail, and internet
Being open to change and considerable variety in work activities; effortlessly adjusting to new or changing situations and unexpected events; altering one's approach to tasks and projects with minimal loss of efficiency
·Independence and Teamwork
Ability to work both independently and in a team environment
·Analysis - Basic
Analytical ability sufficient to evaluate data, make judgments and recommendations
Ability to independently work through details of a problem to reach a positive solution
·Communication - Advanced
Excellent verbal, written and interpersonal communication skills.
Ability to react quickly in analyzing discrepancies in often real-time patient care and safety issues. Ability to differentiate between primary and secondary source systems and databases. Working knowledge of accreditation processes.
·Bachelor's Degree in a related fieldPreferred:
·2 years related experience