Performs analysis of inpatient and outpatient records to assure their completeness. Assigns physician deficiencies in a timely manner. Monitors incomplete records, provides notification to physicians of delinquencies and performs physician suspension when required. Provides back up for HIM receptionist as needed assisting physician offices and patients with requests. Provides back up for HIM representative as needed assisting with scanning inpatient and ACU charts
Analyzes all inpatient and outpatient records for completeness, assigns physician deficiencies in electronic health record. Maintains analysis completion at 1-2 days 95% of the time. Goal of analysis is to have it completed prior to coding.
Performs physician notification of incomplete records on a daily and weekly basis by sending reminders to physicians including making phone calls when necessary. Notification is sent once a week to ER Medical Director for all ER physicians. Reminder notice sent every Wednesday for incomplete records <15 days old; 72 hour reminder notice sent the following Wednesday for records remaining delinquent. Notification of suspension sent after 72 hours for records remaining delinquent. For operative reports, reminder notice is sent 48 hours after surgery; if operative report is not completed, notification of suspension will be sent after 24 hours of first notification.
Performs physician suspension for delinquent records, reinstates physician when records complete. Keeps track of monthly suspension days and reports these to the HIM Manager at the beginning of the following month.
Works closely with physician and physician offices to help resolve any issues related to record completion. Also works closely with information services on issues related to problems physicians may have encountered.
Monitors pending documentation queue in electronic health record to make sure physicians are notified of documentation holding up coding and notifies coder when documentation is available.
Monitors and performs follow up on missing documentation work queue in electronic health record for missing diagnosis codes on orders; notifies coder when documentation is available. Provides assistance with correcting errors in scanning in the electronic health record.
Monitors reanalysis and decline queues in electronic health record to verify physician completion and investigate possible reassignment of deficiencies, if appropriate. Works with physician to resolve issues related to these deficiencies.
Assists with quality reporting by completing quality review of surgical H&P's. Performs uploading of ambulance records from ambulance website into electronic health record; this is performed daily.
Provides back up for HIM receptionist as needed assisting physician offices and patients with requests, assists with scanning loose sheets. Provides back up to HIM representative for inpatient and ACU scanning as needed.
Education: High School Diploma or equivalent.
Experience: At least one year previous experience in acute care hospital or clinic setting with responsibility for maintaining documentation completeness in an electronic medical record environment.
License or Certification: RHIA, RHIT, CCS or CCA desirable, or actively pursuing.
Required Skills or Knowledge: Possess knowledge of CIHQ, federal and state patient record completion requirements; thorough understanding of Medical Staff rules and regulations as related to chart completion. Good communication skills required to be able to explain physician deficiencies and assist physicians in their record completion.
Actual compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Eligible roles also qualify for a comprehensive benefits package.
USD $26.51
USD $34.47
Sonoma Valley Hospital (SVH) is a 51-bed, full-service acute care district hospital located in the city of Sonoma, California, and serving a population of approximately 42,000 people residing in the Sonoma Valley Health Care District. SVH is the sole local provider of acute inpatient care and offers a 24-hour emergency room, inpatient services with an ICU, surgical services and outpatient clinical testing and treatment.
In recent years, the hospital has undergone extensive renovation including opening a new wing with a modern Emergency Department and Surgery Center. In 2018, the hospital announced affiliation with UCSF Health. The hospital is fully accredited by the Center for Improvement in Healthcare Quality (CIHQ), meeting national standards for healthcare quality and safety.
