Medical Records Compliance Specialist
2 weeks ago
JOB SUMMARY:
The role involves compiling, scanning, processing, and maintaining medical records in accordance with medical administrative, ethical, legal, and regulatory standards. The position requires proficiency in utilizing an electronic health record (EHR) system for inquiries, data entry, and report generation. Responsible for the appropriate release of medical information.
ESSENTIAL FUNCTIONS:
Conducts thorough analysis of EHR for each discharged patient across various care settings, including inpatient, observation, same-day surgery, and emergency departments, ensuring the completeness and accuracy of medical charts.
Abstracts critical data for collection, including information from primary, secondary, and consulting providers, as well as accurate admission and discharge timestamps.
Utilizes current deficiency database information to log deficiencies in an Excel format, which is shared during medical records committee meetings and with regulatory entities.
Informs the HIS director or team leader regarding records that remain deficient over extended periods.
Completes quality assurance studies and projects upon request.
Updates and revises policies and procedures as needed.
Scans all paper-based records into the EHR, ensuring proper categorization as per standard protocols.
Generates daily reports to identify patients assigned new medical record numbers, ensuring appropriate retention and deletion of records.
Responds to phone inquiries promptly and courteously.
Conducts daily rounds to gather all discharged patient information from care units.
Abstracts and submits birth data to the state registry for all newborns.
Maintains confidentiality regarding medical information.
Processes requests for information release to patients, insurance companies, other providers, recovery audit contractors, and workers' compensation, adhering to HIPAA guidelines.
Reviews authorizations for release specifications, particularly in sensitive areas requiring specific consent, such as mental health, substance abuse, and HIV.
Aims to guarantee prompt information release for patient care and within a five-business-day timeframe for all other requests.
Maintains organization of NST strips received from obstetrics, ensuring they are orderly and accessible for providers as needed.
Compiles and maintains daily admission and discharge statistics, sharing this information with finance, utilization management, and other departments at the end of each month.
Performs mailroom duties as assigned.
Engages in ongoing educational training and professional development.
Undertakes additional related duties as deemed beneficial for the organization.
Actively participates in all employee safety program initiatives.
Collaborates as a member of the HIS team to promote a culture of safety within the department and across the organization.
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