Description
Analyzes, abstracts, and reviews, inpatient, same day surgery, emergency room, Chestnut Ridge inpatient and observation charts to ensure completeness for billing, TJC, Corporate Compliance Plan, HCFA documentation requirements, WVMI, ACOS, and other accrediting agencies and third party providers. Responsible to ensure proper validation and authorization for requests for release of protected health information from WVUH properties in various media formats. Responsible to ensures proper document capture and documentation correction for protected health information in all hospital systems as appropriate.
Essential Duties and Responsibilities: include the following. Other duties may be assigned.
Analysis of inpatient, same day surgery, emergency room, Chestnut Ridge inpatient and observation charts to ensure completeness for billing, TJC, Corporate Compliance Plan,
HCFA, ACOS, WVUH Bylaws and Rules and Regulations, as well as UHA guidelines, and other accrediting agencies.
1 Analysis of all charts inpatient, same day surgery, emergency room, Chestnut Ridge inpatient and observation by reviewing all pertinent data, identifying incomplete documentation for billing, TJC, Corporate Compliance, HCFA, ACOS, WVUH Bylaws, Rules and Regulations, UHA and other accrediting agencies. Determines the responsible staff, assigns deficiencies to resident and staff physicians for completeness. Standard rate of twelve (12) charts analyzed per hour for inpatient, SDC thirty-five (35) charts analyzed per hour, and OBS twenty-two (22) charts analyzed per hour..
2 Assigns deficiencies for each deficiency type by physician in Horizon Patient Folder and Merlin.
3 Analysis of all charts for orders and other printed documentation,
identifying deficiency for required signatures, dates and times.
4 Reviews and assigns undictated Discharge Summaries, Operation Reports, and Catheterization Reports in a timely fashion.
Monitors and generates reports for all deficiency and suspension data, reporting to the Vice President of Medical Staff Affairs, Health Information Management Director and Health Information Management Manager of Technicians in order to comply with TJC Delinquency Rates, Corporate Compliance Plan, HCFA, Hospital Bylaws and Rules and Regulations.
1 Updates all data as necessary for timely and accurate reporting, for example: completed deficiencies, reassignment of deficiencies, and physician absences when notified.
2 Produces reports for suspension of physician privileges, unbilled accounts, statistical analysis for TJC, reports for hospital administration,
committees, and productivity reports.
3 Works to ensure the completion of dictated reports and maintenance of accurate
undictated lists. Ability to scan the dictation system as needed to verify completion of dictation deficiencies.
Communications with the Medical Staff to ensure accurate and timely completion of all deficient charts and documentation for TJC, Corporate Compliance Plan, ACOS, HCFA, WVUH Bylaws Rules and Regulations, and UHA requirements.
1 Utilizes all communication mediums; paging, e-mail, voice mail, and facsimile, to notify physicians of undictated documentation, chart deficiencies, timelines for completion, and suspension status as appropriate.
2 Responses to all physician requests navigating HPF, assisting physicians with completion of documentation, and answering minor questions regarding coding and DRG’s, Hospital Bylaws Rules and Regulations issues, TJC, ACOS TNM Staging forms, and other reimbursement issues. Problem responses will be referred to the appropriate Manager.
3 Prepares reports of all delinquent charts and physicians that are eligible for suspension. Verifies correctness of the data, updating as necessary.
4 Prepares and distributes suspension notices via email to Vice-President of Medical Staff Affairs, notifies HIM Manager of Technicians, HIM Director of pending suspensions.
Completion of TJC Record Analysis and other review activities.
1 Participates on the TJC Continuous Record Review Team, completing analysis of the records.
2 Completes the forms for TJC Closed and Open Record Review, submitting finding to the HIM Management.
3 Assists with other review activities.
Completion of Registry Audits in coordination with Medical Staff Affairs and Nursing Services for certification accreditations.
1 Responsible for abstraction of TJC data elements for Restraint compliance and enter abstracted criteria into database for restraint audits.
2 Responsible for other audits as assigned, for TJC IM Standard Compliance such as H&P, Legibility, etc.
Completion of abstraction of data for TJC Stroke Certification Accreditation and WVUH Stroke Registry.
1 Abstracts data for all treated stroke patients at WVUH for appropriateness and timeliness of care.
2 Submits abstracted data to Medical Staff Affairs for reporting to TJC and other accrediting agencies as appropriate.
3 Maintains knowledge base of definitions of strokes, treatable conditions, and the appropriate process of care for stroke diagnosed patients,
and knowledge of documentation abstraction skills.
Completion of abstraction of data for WVMI 7th Scope of Work focus areas.
1 Abstracts data for patients meeting 7th Scope of Work focus areas:
a) Acute Myocardial Infarction (AMI)
b) Congestive Heart Failure (CHF)
c) Pneumonia
d) Surgical Infection Procedures (SIP)
2 Enters data into Access Database for Medical Staff Affairs for statistical compilation, data reporting, and compliance of participation in
7th Scope of Work.
3 Maintains knowledge base of diagnoses, treatment and abstraction data for all 7th Scope of Work focus areas:
a) Acute Myocardial Infarction (AMI)
b) Congestive Heart Failure (CHF)
c) Pneumonia
d) Surgical Infection Procedures (SIP)
Performs specific system maintenance on the Deficiency Analysis Network in Horizon Patient Folder.
1 Responsible for compiling and generating reports for medical staff credentialing, statistical information, and compliance for TJC, Corporate
Compliance Plan, and HCFA requirements.
2 Maintains up-to-date definition tables in the deficiency analysis program, updating regularly any changes in medical staff personnel, and
departmental changes.
3 Performs other network system maintenance as necessary and appropriate, including software manual upgrades and testing, modifications,
and network problems. Notifies IT Help desk when problems arise for correction.
9 Perform software and scanner maintenance setup daily by work assignment.
1 Initiate and activate scanner by using Microsoft Windows daily.
2 Assess and evaluate scanner set-up properties based on work assignments.
3 Must understand the difference between feeder and flatbed adjustments.
4 Reset scanner based on specific work assignment (i.e. colored documents).
5 Performs daily maintenance (i.e. paper jams) and weekly cleaning of scanners.
10 Communication / Confidentiality
1 Communicates clearly and effectively both orally and in writing to a variety of customers and end-users.
2 Maintains patient confidentiality by not revealing and/or discussing patient information with anyone who does not have a legitimate interest in the
information.
3 Observes attorneys, patients, et al, reviewing records as necessary, responding to questions with regard to maintenance of Protected Health
Information.
4 Monitors faxing and printing of patient records to ensure legitimacy and accuracy when necessary.
5 Uses good judgment and discretion when dealing with physician offices concerning access to and availability of records.
6 Works as a team member with Management, co-workers, and other departments.
11 Scans and indexes medical records for optical imaging and routes finished documents to appropriate areas.
1. Selects appropriate imaging cabinet based on assignment.
2. Scans documents by placing in optical scanning equipment.
3. Downloads data in existing digital format when necessary.
4 Indexes
