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 communicating and following-up with physicians and other health care providers regarding medical record completion to coordinate chart completion in a timely and cooperative manner, validating practitioners’ deficiency lists, timely notifying physicians of pending records that need completion, preparing the physician suspension list, assisting in expediting the completion of priority records needed for Release of Information, orienting new physicians to HIM chart completion processes, and applying knowledge of TJC standards, Medical Staff Rules & Regulations, general regulatory requirements and health system policies and procedures. Qualifications include a high school diploma or equivalent, experience and training in acute care and health information management processing, preferred RHIT, RHIA or equivalent credentials, one year of experience in Health Information Management with chart analysis and regulatory knowledge, and preferred experience in electronic medical records processing. Required skills include knowledge of medical record format and content, typing ability, computer skills, medical terminology, regulatory requirements, organizational skills, attention to detail, teamwork, ability to work under pressure, initiative, and excellent communication skills. Physical requirements include extended sitting, reaching, bending, pushing, pulling, visual acuity, dexterity, and light to moderate lifting. Cape Fear Valley Health System is an Equal Opportunity Employer.
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