Understands the necessity for timely completion of medical record documentation by analyzing medical records for missing documentation and signatures. Compares the documentation in the medical record against required standards and enters deficiencies for providers in the electronic medical record system. May be assigned other HIM functions to support departmental workflows. Understands regulatory standards for accurate medical records. Performs record analysis by abstracting and recognizes the relation of a complete medical record. Applies knowledge of disease processes, anatomy, physiology, medical terminology, state laws and other regulatory standards in the analysis of the medical record. Utilizes job specific software in analysis and monitoring functions. Maintains software system competence including the electronic medical record (EMR) and document imaging at a high level. Completes admission and discharge related functions including retrieval of previous medical records. Scans and captures documents in an extremely timely manner, and confirms capture clarity and quality. Indexes medical record documents using document imaging software. Completes document imaging accuracy checks and audits. Monitors timeliness and completion of various medical record components to assure Federal/State regulatory compliance. Enters and maintains medical professional information in the EMR. Requires knowledge and application of coding guidelines and regulations in the assignment of diagnosis codes and sequencing specific to location and department guidelines. Assigns codes to appropriate medical diagnoses based on review of supporting documentation, and ensures these are captured for timely and accurate billing for all payers. Maintain application of facility policies and standards of practice to assure release of information requests (ROI) are appropriate and meet legal regulations. Processes ROI requests within requested timeframes. Prepares and generates reports as requested. Will work extensively with protected health information and is required to adhere to health insurance portability and accountability act (HIPAA) privacy and security regulations and policies related to the same. Handles requests for release of information according to policies, and maintain security of health information and medical records. Supports and educates others on managing private information. Prepares and participates in Health Department survey activity. Supports providers and other clinicians on EMR usage and workflows.
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