Job Description
Handles tracking, notification, and updating of all discharged (Inpatient and day-case) health records as identified through the chart analysis so as to ensure timely and accurate completion of patient health information and minimization of delinquent records
Responsibilities
- Analyzes health records to identify any missed and incomplete documentation and enter these as per the electronic tracking system.
- Reviews automatically assigned deficient records to ensure accuracy.
- Reviews all documentation for chart completion and performance improvement.
- Separates and files analyzed records in appropriate filing areas.
- Pulls incomplete records for physicians and ancillary staff and assists with record completion queries.
- Reviews incomplete records report weekly; prepare individual physician lists, clarifying deficiency types. Â
- Sends incomplete records notices to Nursing and Allied Health Departments as appropriate.Â
- Completes secondary record analysis, following completion of records by clinical personnel.
- Provides physician training on incomplete records process.
- Tracks and files all completed records in the appropriate filing system.
- Updates the incomplete records application in the tracking system. Â
- Maintains confidentiality of all data and information at all times. Â
- Performs duties of Coordinators during periods of absence.
- Supports the ROI Section during times of high workload and/or absences. Â
- Performs other applicable tasks and duties assigned, by the Director of Health Information within the realm of the employee’s knowledge and skills and abilities.
- Completes all assigned tasks in a timely, standardized appropriate format.Â
Qualifications
- Third-level education, with clinical/healthcare certificate/diploma preferred:
- Clinical Degree
- Medical Record Technology
- International Classification of Diseases Coding (ICD) Coding
- Medical Transcription
PROFESSIONAL EXPERIENCE:
- Minimum of three (3) years of experience in a healthcare setting in either Health Information Management (HIM) or Medical Records Department (MRD).
- Knowledge of current clinical documentation templates and forms.
- Knowledge of legal record requirements and confidentiality laws.
- Knowledge of medical terminology, appropriate level of healthcare and healthcare delivery systems.
- Skills in the correct usage of software applications.
- Skills in chart analysis, medical terminology and health record maintenance
- Skills in using software: Microsoft Office Word/Excel/PowerPoint.
- Ability to speak and write in English fluently