HIM Documentation Analyst

Responsibilities

• Reviews, analyzes and ensures completeness of patient charts in compliance with hospital, state and regulatory standards.
• Reconciles content of electronic medical record (EMR).
• Manages provider chart completion performance.
• Prepares weekly documentation deficiency reports and sends reports to the appropriate provider.
• Researches declined or miss-assigned deficiencies, including orders and documentation to determine appropriate resolution.
• Mastery in retrieving, verifying and releasing all data elements necessary for audits such as RAC, OIG, and PBFS/UMB for compliance purposes according to state, federal and other regulatory agencies.
• Communicates and coordinates with divisions to obtain access and gather necessary documents for release of information.
• Analyzes and abstracts patient charts to complete vital statistics records.
• Interviews obstetrical patients and prepares birth certificates. Electronically transmits birth certificates to the State Health Department.
• Captures and coordinates with families and appropriate departments to assist with paternity requests and adoption issues.
• Determines appropriate document content and data elements necessary to be retained in the legal physical and electronic medical record and works with the Clinical Documentation Committee on forms content review.
• Acts as liaison between HIM Department, Document Control Library Committee, and hospital staff concerning document submissions and approvals.
• Creates and edits patient forms using standard templates in compliance with Document Management System and LMR Requirements.
• Prepares documents to be published through document control library approval steps.
• Scans medical records into the EHR and assists in training for institution wide scanning.
• Performs quality control audits and error correction activities on scanned documents.
• Trains HIM staff, healthcare providers and others in established procedures.
• Audits medical records to ensure compliance with departmental and regulatory requirements, providing feedback on quality measures and proper documentation.

Qualifications

• Demonstrated proficiency in role-specific HIM department functions.
• Three years of experience in a healthcare environment, or equivalency.
• Advanced knowledge of medical terminology, anatomy and physiology, and HIPAA regulations.