Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Clerical

Work Shift

Days (United States of America)

Summary

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. Consistently assists with quality, integrity and related chart reviews.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Organizes, analyzes and technically evaluates 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.

• Assists bereaved families with information about releasing the deceased to a funeral home and by explaining paperwork to the families.

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• High school graduate or equivalent required

Work Experience: 

• One year of experience in Health Information Management required

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language

• Knowledge of general medical record format and content

• Should demonstrate the ability to type 40-45 wpm accurately or demonstrate sufficient keyboard familiarity to perform job functions

• Must have intermediate experience in the use of computers in a Windows environment

• Basic understanding of medical terminology

• Knowledge of Joint Commission and other regulatory agency chart documentation requirements

• Good organizational skills with the ability to manage multiple priorities and make good independent decisions

• Attention to detail and quality to include strong recall and recognition skills

• Ability to work in a team environment as well as work alone when necessary

• Ability to work under pressure with ongoing time constraints

• Initiative and ability to provide excellent customer service to enhance patient care delivery by assuring timely and accurate access to medical records

• Excellent written and oral communication skills

Physical Requirements: 

• Extended periods of sitting, with some instances of reaching, bending, stooping, pushing, and pulling all requiring use of proper body mechanics

• Ability to work productively in a high volume, high stress work environment

• Visual acuity for reading and processing charts/information

• Dexterity of upper extremities and fingers, as well as mental dexterity for accurately sorting medical record documents

• Light to moderate lifting of plus or minus 25 pounds of boxes containing medical record documents

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity