CLINICAL DOCUMENTATION ANALYST Full Time Days

About the role

Reviews accuracy and completeness of medical records to ensure compliance with hospital and regulatory guidelines. Works with clinical staff/physicians to gather missing information for patient medical records.

Responsibilities

• Analyzes Inpatient, Observation, and Same Day Surgery records to assure timely completion and accuracy.
• Maintains analysis backlog on Inpatient, Observation, and Same Day Surgery records within 5-7 days of discharge.
• Accurately identifies, assigns, and updates all deficiencies for providers.
• Performs quality assurance (QA) on scanned records for Inpatient, Observation, Same Day Surgery patients.
• Performs rescans of completed medical records within 3 days of completion.
• Audits discharge analysis work list bi-monthly to ensure all Inpatient, Observation, Same Day Surgery patient medical records have been analyzed.
• Reviews completed dictations morning and afternoon; assigns and removes dictation deficiencies accurately and timely in HIM software.
• Sends written notifications for impending delinquent deficiencies to medical staff department heads and Chief of Staff before creating the No Admit/No Clinical Privileges List.
• Creates the No Admit/No Clinical Privileges List on the first of the month according to regulatory and hospital guidelines; monitors and updates the list daily.
• Affords assistance to physicians/practitioners with completing medical records, including taking/picking up incomplete records to and from the surgery lounge.
• Affords assistance to coworkers as needed in a courteous and professional manner.
• Utilizes hospital resources and time respectfully and accountably.

Requirements

• Minimum Education: Associates Degree
• Preferred Degree: Health Information Management or related field
• License/Certification Required: Registered Health Information Technician (Prefered)/Registered Health Information Administrator
• Minimum Work Experience: 2-3 years experience in Health Information Management preferred
• Proficient in the use of computers with knowledge of Microsoft Word and Outlook
• Ability to maneuver through several computer programs
• Knowledge of medical terminology
• Strong organizational and time management skills
• Excellent interpersonal and customer service skills
• Ability to interact with persons of varying backgrounds and education levels