Description

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

Position Responsibility:

• 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.
• Sends incomplete records notices to Nursing and Allied Health Departments as appropriate.
• 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.
• Maintains confidentiality of all data and information at all times.
• Performs duties of Coordinators during periods of absence.
• Supports the ROI Section during times of high workload and/or absences.
• 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.

Position Qualification:

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