PURPOSE OF POSITION: Responsible for: Analysis and or reanalysis of electronic medical record documentation for completeness, identifying, tracking, and reporting deficiencies, works closely with the medical staff in troubleshooting and resolving deficient and or delinquent documentation findings, and reports completion status to CCHMC leadership. Reviews transcribed notes for accurate demographic information, provider authentication, and correct formatting. Provides basic customer service and release of information support such as answering telephones, validation and or data entry of authorizations to release protected health information in order to facilitate request processing and provide timely feedback regarding status of Release of Information requests.
·Serve as a Resource
Train and provide guidance and support to newly hired HIM Clinical Documentation Integrity Technicians on all aspects of job duties and on all policies and procedures related to job duties. Provide feedback to management on progress of training. Participate in testing scenarios for system implementation and upgrades. Provide training and support, as necessary, to the medical staff on completion of the electronic medical record. Act as a resource to the medical staff and administrative staff and other customers regarding medical record completion and transcription policies and procedures. Communicate with the Medical Staff Office regarding physician delinquencies or related issues. Demonstrates flexibility in work assignments such that needs of all customers are met. Provide basic troubleshooting as a response to problems and issues identified by physicians, managers, administrative support staff, etc. and pose solutions.
·Documentation Integrity: Chart Completion
Reconcile operative report dictation. Resolve physician suspension issues. Identify documentation issues and initiate discussion to resolve. Support coding by following up on data integrity issues and other questions, providing timely communication and resolution. Provide technical and administrative assistance for other health information functions. Complete special projects as assigned. Utilizes electronic work lists and workflow reports to analyze electronic medical record documentation for completeness and identify deficiencies (e.g. dictation, signature). Enter and track deficiencies in computer application. Reanalyze records and modify deficiencies and or date fields to reflect pending documentation. Print and distribute or electronically notify the physician of record completion deficiencies and or delinquent medical records in a timely manner. Troubleshoot deficiencies that have been rejected and or declined by the assigned physician. Process the Attending Delinquent Record List according to established procedures. Perform basic level troubleshooting to assist physicians in clarifying deficiencies, answering questions, and addressing concerns to ensure prompt record completion and good customer service.
·Documentation Integrity: Transcription
Monitor the completion of dictations within the timeline established by CCHMC and process the Incomplete Operative Report Dictation List according to established procedures. Resolve physician suspension issues. Support coding by following up on operative note data integrity issues and other questions, providing timely communication and resolution. Provide technical and administrative assistance for other health information functions. Monitor the fax server to research and or correct entries as appropriate. Complete special projects as assigned. Utilize electronic work lists and workflow reports to review and edit medical record transcription for: accurate patient demographic information, accurate physician signature deficiency assignment and correct formatting in ChartMaxx. Validate that transcription is applied to the proper medical record encounter and move as appropriate.
·Documentation Integrity: Release of Information
Reviews, validates, and enters authorizations to release protected health information to ensure compliance with HIPAA requirements, works with requestors such as families, patients, providers, auditors, etc. to facilitate request processing and provide timely feedback regarding status of requests, processes routine and or first level disclosure of copies of medical records to meet turn-around time goals (verification of discharge dates to insurance companies, release of immunization records, disclosure of records from Epic and or CMaxx for continuity of treatment purposes, uploading images to PACS Computer Application, burning CDs for internal and external customers, etc.).
·Productivity and Quality
Perform quality review during the training phase for CDIT staff. Maintains production and measurement statistics. Consistently meet department productivity and quality standards. Maintain a neat functional work space that is organized, safe, accessible, and that provides an effective and efficient environment for employees, patients, and families.
Effectively demonstrates communication skills related to conveying information. Promptly answers the telephone, acknowledge, greet, and assist any HIM Department customer. Researches information following well defined paths and responds to requests. Prioritizes multiple requests. Interact effectively with peers, medical staff and other internal/external customers of the HIM Department. Presentation skills sufficient to provide training for viewing medical records to other HIM department staff, medical staff, ancillary staff, etc. Orients new staff to the department Function as an effective team member within individual teams and departmental teams.
Provides assistance to other CCHMC staff members and customers. Answers telephone calls, responds to status requests for release of protected health information adhering to HIPAA, CCHMC and HIM department standards, prioritizes requests for information, troubleshooting issues and escalating as appropriate. Processes first level requests for patient information in a manner that adheres to HIPAA and HIM Department standards. Researches requests to update the patient care team in Epic, updating as appropriate. Demonstrates flexibility in work assignments such that needs of all customers are met. Functions as an effective team member within individual teams and departmental teams.
Skills & Competencies
Using time efficiently and productively; prioritizing multiple tasks properly to meet deadlines; recognizing time constraints and adjusting work schedule to address them.
·Workflow - Basic
Basic understanding of workflow
Expressing oneself verbally in an accurate, understandable, and succinct manner to individuals or groups; using appropriate non-verbal signals to emphasize spoken words; adapting communication style and tone to fit the situation and audience; demonstrating poise during group discussions or formal presentations; holding others' attention; responding clearly and tactfully to questions
·Data Management - Basic
Basic knowledge of data management methodologies and technology sufficient to protect information
Proficiency in basic computer applications such as Microsoft Office (PowerPoint, Word, Excel), 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
Strong organizational and project management skills to handle projects independently.
Demonstrates an independent work initiative, sound judgment, diplomacy, tact and professional demeanor
Identifies problems and asks questions; escalates when appropriate
Excellent verbal, written and/or interpersonal communication skills
Demonstrate the ability to work with a diverse group of people. 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.
·Independence and Teamwork
Ability to work both independently and in a team environment. Participate collaboratively in staff meetings, committees, projects and teams to resolve conflicts and/or meet institutional goals. Is recognized as an informed participant or committee member by peers and HIM management.
·Customer Service/Conflict Res
Able to handle sensitive issues and defuse frustrated and/or angry individuals both in person and on the telephone, while recognizing when to escalate to an HIM manager.
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
·High School Graduate OR equivalentPreferred:
·Two years of experience in an office setting
·Basic knowledge of medical terminology