Job Description

Schedule

Full-Time: Monday-Friday 8am-5pm, potentially 10am-7pm on Tuesday and/or Thursday. Remote options available after successful probationary period of 120 days.

SUMMARY

Under the direction of the Outpatient Clinical Services Director the Outpatient Records Specialist will conduct audits of patient case records for the purpose of identifying documentation errors. The Outpatient Records Specialist is responsible for reviewing and verifying the overall quality and completeness of clinical documentation. This individual facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, and counseling staff to ensure that completed documentation reflects a clear and accurate depiction of services delivered and the chart complies so the service can be billed for and paid by the insurance company and meets all regulatory and agency procedures. In addition, the Outpatient Records Specialist will be responsible for extracting, compiling, and reporting data from the electronic health records system. The Outpatient Records Specialist will provide ongoing monitoring and systematic review to ensure that entries in records follow established procedures to meet accreditation requirements. This role may provide training in records management to assist the clinician and organization in improving the quality of services provided to each person served.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Works with the Outpatient Clinical Services Director and the outpatient management team to complete full audit of patient health records.
• Ensures all services provided by the programs can be paid for by insurance companies, by maintaining documentation compliance in accordance with the directives and guidelines of the OASAS, OMH, OMIG, DOH, CARF and/or any other governing or licensing agencies.
• Acts as liaison to inform the appropriate staff member (all staff documenting in the patient record) of any documentation errors that are found during quality assurance documentation reviews and trainings.
• Review both concurrently and retrospectively medical records and pertinent documentation in accordance with established site review tools and company policy.
• Extracts, compiles, analyzes, and reports on data from the electronic health records system.
• Prepares periodic reports on quota, waiting lists, case type, acuity level, demographic information, and other criteria as specified. May be asked to present findings.
• Utilize MS Excel spreadsheets to track documentation workflow and provide status reports in the form of tables, charts, and graphs.
• Addresses EHR help desk tickets as trained and directed.
• Communicates with billing department the readiness of services to be billed.
• Upholds the standards of the agency’s Continuous Quality Assurance Program.
• Participation in Continuous Quality Improvement Committee meetings, as assigned.
• Maintaining documentation, correspondence, and communication to and from other providers regarding psychiatric, medical and substance abuse services
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
• Will provide training to clinicians and administrative staff. Will be required to perform other duties as requested, directed or assigned.
• Performs other duties as assigned or that may develop.
• Management has the right to add or change the duties of this position at any time.

Requirements

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

Required: a High School Diploma or GED

Preferred: A two-year degree in the field, particularly in statistics, math, business administration, or computer science

CERTIFICATES, LICENSES, REGISTRATIONS

Required: Must maintain valid driver’s license and acceptable driving record.