- Serve as technical expert in health record content and documentation requirements.
- Perform quantitative and qualitative reviews of health record documentation.
- Ensure all patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed.
- Adhere to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements.
- Review records for adherence with CMS guidelines related to student, resident supervision, and attending physician presence and documentation.
- Compile reports to insure provider specific and service compliance.
- Maintain a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards.
- Assist clinicians with completion of delinquent/incomplete health records.
- Perform quantitative and qualitative analysis on both computer and paper-based health records.
- Consult with the appropriate clinicians for clarification when conflicting or ambiguous information appears in the health record documentation.
- Identify health record deficiencies, track deficiencies, and ensure the appropriate individual completes their deficiencies.
- Assist physicians with completion of delinquent/incomplete health records and serve as the expert resource for clinical staff regarding requirements for complete documentation.
- Expedite completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agency review, and reimbursement purposes.
- Assess paper health record and electronic Computerized Patient Record System (CPRS) for completeness and note deficiencies.
- Track electronic signatures, document deficiencies, and communicate the deficiencies to clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system.
- Prepare complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submit the reports to the appropriate administrative and clinical staff.
- Preform analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient the report belongs too and filing/assigning it correctly.
- Make appropriate recommendations for changes or solutions and implement appropriate recommendations for corrective action when authorized so continued filing errors do not occur.
- Compare and resolve discrepancies between daily Gains and Losses Sheet, Digital System Workload Report, and contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor.
- Review health record for adherence with guidelines related to resident supervision and attending physician presence.
- Work with interdisciplinary staff to solve problems regarding proper health record documentation and completion.
- Obtain statistical information, apply statistical formulas, and complete statistical reports for medical center management.
- Participate in routine and focused reviews to identify problems and potential problems in health record documentation as part of the health record review process.
- Perform lead functions over MRT (HIT) positions and provide guidance and technical direction necessary for accomplishing the work of the unit or team.
- Serve as work leader, assuring work assignments of employees in the unit are carried out.
- Distribute and balance workload and tasks among employees.
- Communicate the problem to be solved or program issues under review and coach the team and/or individual team members in identifying the parameters of a viable solution.
- Ensure the organization's "vision" is integrated into team goals, strategies, activity plans, and work products.
- Ensure team members participate in both short-term and long-term planning stages of team projects.
- Maintain knowledge and answer questions from team members on procedures, policies, and directives.
- Obtain needed information on decisions from the supervisor on major issues and problems that arise.
- Resolve simple informal complaints of employees and refer more serious matters to the supervisor.
- Make recommendations to supervisor as requested concerning promotions, reassignments, and recognition of performance.
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Lead Medical Records Technician - Spokane, United States - Department Of Veterans Affairs
Description
Summary
The Medical Record Technician (MRT) - Health Information Technician (HIT) performs incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.
Duties
Some of the duties, roles, and responsibilities of the Lead MRT HIT include:
Telework: 100% but must live within commuting distance of Spokane, WA.
Virtual: This is not a virtual position
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
