Job Description

Performs extensive reviews of patient records to confirm that documentation requirements of accrediting and other regulatory agencies are met. Independently coordinates, monitors and follows-up timely on chart completion issues and physician complaints in this regard. Releases patient records and information consistent with established guidelines. Based on demonstrated knowledge, experience and senior status also serves as point of contact for chart completion issues and training of new staff. Also, consistently assists with quality, integrity and related chart reviews. This is an ONSITE POSITION. Major job functions include organizing, analyzing and technically evaluating patients' records to confirm that documentation required by JCAHO, HCFA and other regulatory agencies is present. Consistently refers charts to the correct physician/practitioner for completion. Keeps knowledge of documentation requirements current. Follows up timely and independently on chart completion issues and resolves documentation questions timely so that chart completion is not delayed. Communicates effectively with physicians and other health care providers regarding medical record completion requirements and serves as a point of contact for questions regarding current policy/procedure requirements. Screens patient records for quality assurance, risk management and Medical Records Committee reviews as designated in procedure. Responds to requests for patient medical information, assuring proper authorization in accordance with state and federal law. Serves as point of contact when priority release issues arise. Assists with the 30-day incomplete chart report (DNFB) by consistently verifying its accuracy prior to submission and distribution to Administration, Medical Staff and appropriate departments. Performs concurrent chart analysis as needed to expedite chart completion for billing, reimbursement and/or designated reviews. Obtains information and prepares paperwork for deaths to include in-hospital deaths, stillbirths, medical examiner related cases, deaths occurring in the Emergency Department and DOAs. Supports the Medical Examiner by preparing the Medical Examiner’s death certificate and other essential paperwork. Assists bereaved families with information about releasing the deceased to a funeral home and by explaining paperwork to the families. Coordinates release of bodies with funeral directors and Health System staff. Communicates with other departments and follows-up as needed to obtain outstanding reports which are needed on patient records. Other duties as assigned. Qualifications include a high school diploma or equivalent, one year of experience in Health Information Management, scanning experience strongly preferred, knowledge of general medical record format and content, ability to type 40-45 wpm or sufficient keyboard familiarity, intermediate computer skills in Windows environment, basic medical terminology understanding, knowledge of Joint Commission and other regulatory agency chart documentation requirements, good organizational skills, attention to detail, ability to work in a team and independently, ability to work under pressure, initiative, excellent customer service, and excellent communication skills. Physical requirements include extended periods of sitting, some reaching, bending, stooping, pushing, pulling, visual acuity, dexterity, and light to moderate lifting of up to 25 pounds.

By applying, you consent to your information being transmitted by Jooble to the Employer, as data controller, through the Employer’s data processor SonicJobs.
See Sonicjobs Privacy Policy at and Terms & Conditions at and SonicJobs Privacy Policy at and Terms of Use at

Job Tags

Similar Jobs