Overview
WE ARE HIRING!Location: 225 Abraham Flexner Way Suite 700, Louisville, KY 40202
About UofL Health UofL Health is a fully integrated regional academic health system with nine hospitals, four medical centers, Brown Cancer Center, Eye Institute, nearly 200 physician practice locations, and more than 1,000 providers in Louisville and the surrounding counties, including southern Indiana. Additional access to UofL Health is provided through a partnership with Carroll County Memorial Hospital. Affiliated with the University of Louisville School of Medicine, UofL Health is committed to providing patients with access to the most advanced care available. This includes clinical trials, collaboration on research and the development of new technologies to both save and improve lives. With more than 13,000 team members – physicians, surgeons, nurses, pharmacists and other highly-skilled health care professionals, UofL Health is focused on one mission: to transform the health of communities we serve through compassionate, innovative, patient-centered care. For more information on UofL Health, go to www.uoflhealth.org.
Job Summary:
This position is responsible auditing and analyzing the Legal Health Record (LHR) for compliance with Centers for Medicare and Medicaid Services (CMS) and Joint Commission Record of Care documentation standards. Perform administrative tasks involving electronic chart analysis and document coordination to ensure appropriate criteria are met and maintained in accordance with organizational and department compliance standards. Interacts as needed with internal customers to include but not limited to hospital staff, physicians and their offices, and other revenue cycle team members. Actively participates in department and hospital performance initiatives when needed to ensure ULH success.
Responsibilities
- Performs analysis and re-analysis of the medical record to ensure completeness, accuracy, and timeliness of clinical documentation and compliance with regulatory bodies.
- Serve as the primary contact person and trainer of the physicians in the completion of documentation in the EMR.
- Monitor, provide feedback, and educate Physicians and other providers regarding TJC and CMS standards and Medical Staff Bylaws to ensure workplace and regulatory compliance.
- Performs research and required follow up to obtain, track, and clarify missing, incomplete or questionable patient health information as well as assign appropriate deficiencies for incomplete medical records.
- Assist customers (physicians, patient care units, quality, and other departments internally and externally, etc.) in understanding chart completion requirements.
- Generate and disseminate deficiency and delinquency letters to notify and/or provide helpful reminders to physicians of any outstanding issues with missing documentation, signatures, queries, etc., in a timely manner as established in hospital policy.
- Maintain integrity of chart completion systems and carry out the suspension notification process and suspension policy for unresolved delinquencies greater than 30 days as set forth by the medical staff.
- Perform quantitative and qualitative ongoing record reviews, identify documentation compliance opportunities, prepare statistical reports of trends and outcomes for Medical Records Committee, etc.
- Locate, route, track and coordinate electronic documents and dictations and manage courtesy copy distribution of transcribed reports for continuity of patient care.
- Review and abstract data in response to requests for patient medical record information and for statistical and clinical databases.
- Maintain overall financial viability for UMC Revenue Cycle through collaboration and effective communication with Care Management, Physicians, Coding, and Patient Financial Services.
- Monitors the implementation of appropriate changes to improve accuracy, effectiveness, productivity, and efficiency that support the overall goals of the department and ULH.
- Perform other duties as assigned.
Qualifications
- High School education or GED required.
- Minimum of 3 years’ experience in health information management practices and procedures.
- Experience in reading and understanding medical record data, familiarity with physician documentation, and medical record content.
- Experienced with performing ongoing medical records reviews for compliance with Joint Commission documentation standards under Record of Care for operative reports, H&Ps, authentication, etc.
KNOWLEDGE, SKILLS, & ABILITIES
- Knowledge of Medical Terminology acquired in a classroom setting or obtained through on the job training.
- Demonstrate excellent interpersonal, organizational, written and oral communication skills.
- Ability to operate or learn to operate multiple computer systems and software, document management system, chart tracking system, and master patient index search and retrieve.
- Ability to work independently, problem solve, and prioritize with minimal supervision and positive customer service relationships.
- Strong time management and critical thinking skills and ability to manage multiple demands.
- Knowledge of Federal, State, and HIPAA/HITECH privacy and security regulations governing confidentiality of patient health information.
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