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HIM Chart Completion Associate

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Job ID: 160557
Category: Health Information Management/Coding
Work Type: FT
Location: Plainsboro, NJ, United States
Date Posted: Nov 29, 2022
Work Schedule: FT

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Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Summary:

  • Performs a variety of medical record functions to assure timely and accurate access to and completion of medical records for clinical providers, medical staff members and those with a legitimate need. Employee will be cross-trained in any/all functions of this position, but essential accountabilities will vary with the actual daily duties assigned. Provides direct customer service and collaborates with care providers within the organization and outside the organization to develop and enhance patient care and service. Provides prompt assistance to patients and care providers using excellent critical thinking skills and decision making while following all legal and regulatory guidelines for protecting and releasing medical record information.

Responsibilities:

  • Completes the physician incomplete chart notification process each week according to HIM Department procedures in order to meet all regulatory medical record documentation requirements. The process includes; generating reports, creating spreadsheets, sending emails, updating spreadsheets, suspending non-compliant physicians and reinstating physicians.
  • Notifies physicians they will be suspended according to Medical Record policy. Applies critical thinking skills to know when appropriate. Records the number of Suspensions for each physician. Provides information, stats and feedback to the PMPH Leadership Team as appropriate.
  • Notifies surgeons of any undictated/incomplete operative reports. The process includes; generating the report, creating spreadsheets, checking the EMR and the Dictation application, sending emails, informing Surgical Dept. Chairman and suspending non-compliant surgeons. Applies critical thinking skills to know when appropriate.
  • Reviews the daily import queues from the Transcription vendor containing failed reports. Verifies and updates patient name, medical record number, visit number, and type of report as needed. Communicates with vendor to resolve issues.
  • Instructs physicians and care providers on electronic chart completion as needed within the EMR and assists when appropriate and in accordance with regulatory requirements.
  • Notifies Chief Residents of Resident deficiencies to assist with Resident Chart Completion. Follows up to ensure timely completion.
  • Reviews the EMR Deficiency Work Queues daily. Communicates with the health care providers to ensure accurate and timely documentation. Analyzes records for chart completion and updates deficiencies on incomplete records for physicians to complete.
  • Works with departmental and interdepartmental employees i.e. Dept. Chairman and support staff to aid in timely processing of records. Communicates to Management work status, potential issues and concerns.
  • Accesses and analyzes reports for accuracy of deficiencies, delinquencies and accurate provider assignment. Reports concerns and contacts others to ensure resolution. Informs Management as appropriate.
  • Revises incorrectly documented notes to correct note types. Moves notes and sends recently identified incorrectly scanned documents to Chart Corrections.
  • Assists ROI vendor with contacting clinicians to complete requested medical record documentation. Follows up and informs ROI vendor when complete so records can be released timely.
  • When requested, updates newborn names in the EMR immediately after newborn name information is received.
  • As needed, prepares medical record documents for scanning according to department policy and verifies correct patient identification on each document. Scans documents into EMR using medium and low speed scanners immediately upon arrival to the HIM Department. Maintains the medical record batches in a neat and orderly manner. Properly indexes documents to ensure they appear in the correct location in the correct patient medical record.
  • Identifies new paper forms and paper form issues. Promptly brings concerns to HIM Operations Management attention. Inquirers with Management Team on using correct document types for new forms. Updates the Scanning Document type spreadsheet as appropriate.
  • As needed, assists with sending communication to the physicians for Coding Query Completion. Monitors completion and follows up to resolve issues/concerns.
  • As needed, creates Revenue Cycle reports of unbilled accounts. Ensures data integrity and sends reports to HIM Corporate timely. Tracks accounts with missing information to ensure completion. Follows up to resolve issues/concerns.
  • Assists with special projects to enhance and/or improve workflow and/or patient care. Communicates to Management and staff regarding any special projects in a timely, complete and professional, manner.
  • Responds to emails and phone calls in a timely manner, generally within one business day.
  • Provides direct customer service and supports performance improvement goals of the department, collaborates with care providers, within and outside the Department, to develop means of enhancing patient care and service.
  • Responds to Care providers and patients in the absence of the ROI vendor Team.
  • Performs Quality Review on scanned documents. Documents findings. Maintains spreadsheets. Follows up with staff to inform them of any errors.

Credentials:

  • RHIT or RHIA preferred

Education or Equivalent Experience:

  • H.S. Diploma/GED (Required)
  • Bachelor's degree and 5+ years experience preferred
  • Other
  • Recent graduate of an Associates or Bachelors program or RHIT or RHIA without experience would be considered

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

   Current UPHS employees must apply HERE
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