- Purpose of Job
- Responsible for Quality Assurance (QA) of Methodist inpatient, outpatient surgery, and rehab records to ensure completeness of the record and compliance with regulatory agencies by analyzing records for deficiencies as defined by quantitative analysis procedure
- Job Requirements
- High school diploma, General Educational Development (GED) or equivalent required.
- Requires completion of college level course in medical terminology.
- Participates in mandatory in-service training and continuing education programs as mandated by policies and procedures/external agencies and as directed by supervisor.
- Prefer prior experience in a Health Information department
- Requires knowledge of medical terminology and medical record practices.
- Has a working knowledge of Microsoft Office applications such as Word and Excel, and typing skills of 40 words per minute (wpm) with 95% accuracy.
- Requires the ability to provide transportation to other campus locations within a reasonable timeframe.
- Analytical ability and ability to note detail when reviewing the medical records for completeness.
- Keyboarding experience with typing speed of 40 words/minute.
- Has skills in the operation of office equipment, including the copy machine, telephone, and computer.
- Requires the ability to perform office duties, follow instructions, pay attention to details in a fast paced environment, work under stress, organize work and records, problem solving, work in a team environment, adapt to change and assume responsibility for job accuracy and timeliness.
- Physical Requirements
- Weight Demands
- Light Work - Exerting up to 20 pounds of force.
- Occasionally Performed (1%-33%):
- Distinguish colors
- Frequently Performed (34%-66%):
- Repetitive Motions
- Constantly Performed (67%-100%):
- Not Related:
- Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)
- Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
- Explosives (pressurized gas)
- Electrical Shock/Static
- Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
- Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
- Rare (1-33%):
- Chemical agents (Toxic, Corrosive, Flammable, Latex)
- Mechanical moving parts/vibrations
- Essential Job Functions
- Essential Functions I
Performs initial Quality Assurance (QA) of Methodist inpatient, outpatient surgery, and rehab records to ensure completeness of the record and compliance with regulatory agencies by analyzing records for deficiencies as defined by quantitative analysis procedure.
- Demonstrates knowledge of and applies rules applicable to analysis; i.e., signature/missing document deficiencies assigned correctly as evidenced by spot checks and feedback from Physicians; accuracy standard -–98%.
Abstracts acute care records to maintain a valid database by entering data elements into patient records per department procedure.
- Abstracts medical records per department procedure with 98% accuracy.
Ensures medical records are available for coding and physician completion in order to meet Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards and departmental goals by achieving performance expectations.
- Analyzes and abstracts an average of 5.5 NMH inpatient/observation records per hour.
- Analyzes and abstracts an average of 6.0 MWH/MJE inpatient/observation records per hour.
- Analyzes and abstracts an average of 7.5 NMH procedure records per hour.
- Analyzes an average of 8 recurring outpatient records per hour.
- Analyzes and/or abstracts an average of 25 outpatient records per hour.
- Analyzes an average of 90 emergency department records per hour.
Essential Functions II
Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.
Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.
Other duties as assigned.
- Performs other clerical duties as needed in a timely manner consistent with established procedures.
Methodist Health System