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Health Information Management Documentation Specialist

Company

Penn Medicine

Address , West Chester, 19380, Pa
Employment type
Salary
Expires 2023-07-01
Posted at 1 year ago
Job Description

Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

General Summary Statement

Performs a variety of electronic record management functions to assure timely and accurate completion of records. Provides accessibility to patient records for those with a legitimate business need.

Assists in providing the continuity and operational effectiveness of the Document Imaging System (DIS) by the scanning/indexing patient records/reports and monitoring quality of document images.


GENERAL SUMMARY STATEMENTS

1. Maintains patient records in an electronic format by scanning, indexing, moving, and deleting documents.

2. Performs comprehensive quality control monitors on imaged documents according to departmental policy.

3. Provides assistance monitoring the integrity of system data and access.

4. Problem solves system errors by performing an initial system review and communicate with the Operations Manager.

5. Communicates with the Operations Manager and recommends changes to policies/procedures and system tables as warranted, to assist staff and/or users in meeting work demands.

6. Works with departmental and interdepartmental employees to aid in the timely processing of records and communicates with Operations Manager to keep them informed of the status of work, potential issues, and concerns.

7. Prepares medical record documents for scanning/indexing according to department policy and verifies correct patient identification on each document.

8. Scans/indexes medical record documents using high and low speed scanners.

9. Maintains the medical record batches in a neat and orderly manner.

  • Promotes Electronic Record Completion - retrieves records and analyzes records on-line to support the electronic chart completion and coding process.

11. Ensure information is placed in the patient record to facilitate chart completion and to provide the patient total history when the record is requested for review.

12. Releases medical information upon request, following the established hospital policies (HIPAA compliance).

13. Assists with other functions in the department as needed, e.g. ERAS bags, restocking printer paper in exam rooms.

14. Reviews patient charts for completeness starting 5 business days from procedure or as soon as paper work is available for review to assist chart readiness RN and notification to physician offices of missing items needed.

15. Performs and documents chart checks.

16. Places call to physician offices to communicate incomplete or missing paperwork according to our guidelines.

17. Reports abnormal results to Nurse Practitioner, Physician’s Assistant, Anesthesia Directed RN, PPT RN, and/or Manager as needed.

18. Maintains patient safety.

19. Adheres to the Universal Protocol for Patient Identification and Site identification.

20. Prioritizes and organizes work effectively with assigned shift.

21. Places paperwork, labels, etc. into chart and makes sure all charts are present. Keeps labels to label any outstanding items as they come in.


EDUCATION, TRAINING AND EXPERIENCE; CERTIFICATION/LICENSURE

High School Graduate required, associate degree preferred.

Experience in a hospital’s HIM Department, knowledge of hospital computer systems preferred.

Ability to work under pressure, can concentrate on multiple assignments at once.

Medical terminology and prior computer experience necessary.

Ability to use email and internet.

Ability to speak, read, write and understand English.

SPECIAL EQUIPMENT, SKILLS OR OTHER REQUIREMENTS

Detail orientated.

Ability to work on multiple assignments and prioritize work.

Computer Skills

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.