Medical Records Technician
2 weeks ago
Duties include but are not limited to:
Performs concurrent and ongoing medical record documentation review of the patient chart for data collection and reporting in accordance with Joint Commission standards, VHA directives, and local policies.
Assists with monitoring and reporting to improve and enhance the quality and safety of patient care and to support the medical center's educational environment, culture of learning, and patient safety.
Reviews charts, monitoring, and reporting activities for various programs which includes but is not limited to Resident Supervision, Associated Health Supervision, copy and paste, unapproved abbreviations, and provider specific credentialing and privileging renewal requirements for Ongoing Professional Practice Evaluation (OPPE).
Reviews and analyzes medical record to identify and report documentation that is not in compliance with established policies, standards, and regulations for the purpose of appropriate reporting and action by the supervising practitioner or committee.
Obtains relevant and accurate patient record data, organizes, files, and retrieves reports, correspondence, and numerical data for the preparation of reports, briefings, and presentations.
Reviews analysis of work processes or service delivery practices to identify reasonable and efficient measurement of the quality of the work or the activity and to identify areas of possible improvement as it relates to medical record documentation.
Updates the quantitative and qualitative analysis on medical records to ensure that all component parts are present, accurate, complete, timely, and will meet the established requirements and standards of VHA Directives, policy, and medical staff bylaws.
Develops, produces, and distributes reports and data analysis to leadership, clinicians, and program administrators for use in decision making regarding medical record documentation, quality assurance, and performance improvement.
Uses knowledge of an extensive body of VHA and VALLHCS, Accreditation Council for Graduate Medical Education and The Joint Commission technical rules, guidelines, regulations, and knowledge of the basic objectives and policies governing various management or program operations.
Assesses compliance with regulation and accreditation standards.Knowledge of professional practice standards across all specialties of the healthcare system to review the medical record and contribute to the evaluations for Ongoing Provider Proactive Evaluation (OPPE).
Uses the Computerized Patient Record System, electronic databases, office automation software and other specialty software systems for inputting, presentation and reporting of data for analysis.
Interprets VA regulations, directives, and HCS policies and procedures as they apply to clinical care, documentation requirements, trainee supervision, and medical staff requirements.
Interprets, applies, and reports deficiencies of medical record documentation as required by the regulations, guidelines, and policies.Analyzes policy, regulation, and corresponding data to make informed recommendations and reports for leadership to develop realistic improvement plans for related programs.
Conducts complex analytical studies regarding the appropriateness and documentation of patient care documentation in accordance with medical staff bylaws, professional practice standards, and academic regulation.
Researches the entire medical record and understands the processes and terminology to identify all clinical information and to verify that it contains appropriate documentation for the purposes of the specific review and report.
Analyzes and evaluates the issues involved with each assignment, selects, and applies appropriate guidelines and standard techniques and procedures; and decides on a course of action from many alternatives.
Demonstrates integrity and good judgment in safeguarding security of information.Work Schedule
:
Full-Time, Monday-Friday 8:00am-4:30pm
Telework
:
Available
Virtual:
This is not a virtual position.
Functional Statement #
: 000000
Relocation/Recruitment Incentives
:
Not Authorized
Permanent Change of Station (PCS):
Not Authorized
Fi
nancial Disclosure Report:
Not required
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