Bothwell Regional Health Center Documentation Analyst; 7am-3:30pm; No Weekends; 80 hours ppd in Sedalia, Missouri
The Health Information Management Chart Documentation Analyst & Abstractor monitors the completion and accuracy of the medical record. The position utilizes hospital policies and procedures to perform analysis of medical records for documentation requirements as specified by federal and state regulatory agencies, to include The Joint Commission, and the Medical Staff Rules and Regulations.
JOB SPECIFIC RESPONSIBILITIES AND ACCOUNTABILITIES
Interacts with physicians by telephone, mail and face to face to ensure compliance with chart completion requirements.
Maintains accurate statistical data on chart completion requirements. Prepares necessary delinquency reports and correspondence.
Processes rejected orders from CPOE
Performs analysis of discharge records to ensure all documentation requirements met.
Calculates and abstracts data for trauma registry and documentation quality improvement organizations into approved software.
Performs Master Patient Index (MPI) functions for historical patient record accuracy.
Retrieves paper portion of record from clinical service areas and accounts for all patient records.
Ensures all documentation is prepped, scanned, uploaded and available in the electronic medical record. Spot checks scanned records to assure quality before shredding documents.
Processes the closed chart work list as necessary.
Assists with release of information as needed.
Assists off-site coders as needed
Calculation and entry of injection and infusion charges for ED and Observation accounts.
Perform other job functions as deemed necessary.
High School or equivalent
Post high school education in Health Information Technology or equivalent
Experience in medical office or hospital setting. Two years preferred or equivalent education
External Company Name: Bothwell Regional Health Center
External Company URL: www.brhc.org