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Responsible for interpreting and analyzing records on a daily basis for assigned physicians. Assists other healthcare professionals regarding patient assessements in order to document patient care and facilitate delivery of healthcare services. Chart work up, patient information retrieval and chart abstraction.
- Process requests for medical records both outgoing and incomign from multiple sources.
- Import test results into Electronic Health Record (EHR) in a timely manner.
- Field incoming calls from patients, nurses and other medical facilities adn provide friendly service and support.
- Provide support in locating medical records from internal and external sources as needed.
- Provide support in obtaining records from outside sources to complete chart for patient care.
- Meet quality and productivity standards as established by the department.
- Analyze patient medical records for physician appointments on a daily basis. Analyze, retrieve, and scan needed HIM records in order to facilitate completeness of patient chart for patient care.
- Contact appropriate areas to obtain needed information such as Cath films and CD's. Use of multiple software products, including but not limited to Chartmaxx, Meditech, McKesson, Cerner and other systems as needed to obtain hospital information and office procedures.
- Follow established policies and procedures to contribute to the efficiency of the HIM Department.
- Ability to understand varous reports and place them in appropriate categories in Document Management.
- Work closely with clinical staff and Physicians to ensure clinical abstraction is complete and correct.
- Abstract data into the EHR according to established procedure.
- Assign diagnosis codes to problems, per ICD-10 guidelines.
- Provide administrative/clerical/technical support as assigned.
- Use reference material appropriately and efficiently to facilitate accuracy, clarity and completeness of reports.
- Interact effectively with physicians, nurses, other staff and patients and their family members in person and over the phone.
The Clinical Informaticist is responsible for providing leadership, clinical understanding, and support to the planning, coordination, implementation and sustainment of clinical health information technology (HIT). Works collaboratively with, but not limited to, clinicians, physicians, national informatics, Medical Informaticist Lead and IT to ensure that the needs of the patient care areas are met and project timelines, milestones, and deliverables are on target with the overall clinical IT strategy. Provides input regarding the IT system and the impact on existing clinical standards, processes and forms in such a way as to gain support and buy-in from staff to successfully implement and sustain clinical HIT. Position requires an understanding of clinical processes and HIT needs of the clinical disciplines. Will provide guidance of ongoing strategy based on new models of care and optimization of systems, system integration, workflow analysis, analytics, research, outcomes and metric tracking and quality reporting. Demonstrates organizational and communication skills in dealing with patients, families, physicians, & other health care workers.
- Serves as a liaison between Information Technology IT, the physician community, the clinical community for the design, build, testing, training, implementation, and ongoing optimization of clinically led IT strategies
- Coordinates clinical activities for the clinically led IT strategies, including but not limited to OneCare, applying knowledge and understanding of clinical process, documentation, nomenclatures/languages.
- Provides ongoing support for HIT optimization, including, but not limited to, assisting with deployment of additional system features; coordinating and/or participating in the systems analysis, planning, developing and testing activities as required.
- Participates in regional team activities, including knowledge sharing among peers. Supports other markets as determined by clinical leadership.
- Participates in National/Regional Informatics workgroups as assigned.
- Meaningful Use / MIPS (CMS program(s)) – produce needed reports or data; including data validation where applicable
- Provides reports to Provider supervisors for Quality Incentive programs
- Provides subject matter expertise and other support to all users of the HIT systems. Through the regional change request process, escalates change requests.
- Actively advocates for ongoing system optimization.
- Collaborates with IT to ensure effective communication of upgrades and system downtime for each market.
- Primary point of contact for physicians and other providers related to HIT clinical issues.
- Understands current patient safety goals, and other regulatory requirements, including, but not limited to, meaningful use, ICD 10, evidence based practice, SafetyFirst, and ensures that these factors are considered and integrated into HIT design, implementation, and optimization at a market level.
- Maintains current knowledge of clinical informatics through regular review of the literature, participation in professional organizations, etc; identifies trends, best practices and regulatory requirements impacting matters within assigned scope of responsibility; researches nature/scope of impact on existing activities and takes appropriate action.
- Where applicable, will collaborate with the physician liaison role.
- Establishes and maintains organizational clinical standard content within the electronic medical record systems. This may include, but may not be limited to, incorporation of EBP standards within EHR platforms for practice, order entry standards for both clinician and provider use, and clinical documentation for clinicians and providers.
- Liaison for North Dakota Health Information Network
- Provide support for any hospital or clinic surveys -including but not limited to – at the elbow support for state surveyor staff
- Provide support and/or intermediator with coding and providers
- User Acceptance Testing point person for EMR’s
- Provide guidance and support during planned or unplanned downtime with EMR’s
Under direct supervision, Coder is responsible for abstracts and codes patient records in compliance with coding, billing and data collection guidelines of the organization. This role is typically responsible for less complex coding.
- Accurately abstract information from the medial records into the appropriate coding systems, ensuring compliance with established guidelines.
- Determine the most appropriate diagnosis after a thorough review of the medical records. Work closely with practice staff with regards to coding and assignment of a MS-DRGs (Diagnosis Related Group) and APCs (Ambulatory Payment Classification).
- Code medical records using ICD-9-CM and CPT-4 coding rules and guidelines. Ensure through and compliant coding to support patient records and submission of billing for payment.
- Accurately sequence diagnostic and procedural codes according to organization specified procedures and assigns MSDRG/APC as appropriate. Provide codes various departments upon request.
Coding all of the hospital and office charges, cardiac procedures, imaging procedures and all other services performed by the clinical staff. Review and implementation of processes both new and established.
- Physician and staff education as approved by the Director of Business Operations.
- Read and stay current on all CMS and compliance related issues (Advising Director of any changes or issues that affect the Practice).
- Review documentation and code all missing care-slips to ensure capture of all charges.
- Review procedure logs (from hospitals) obtained from staff to research procedures marked to ensure capture of all charges.
- Review missing charges (obtained from business office staff) to ensure capture of all charges.
- Accurately code hospital, office, imaging and all other clinical charges in a timely manner.
- Obtain working knoweldge of payment posting function, demographics, charge entry and overall business office functions.
- Work with management to increase efficiency and proper use of resources for business office function.
- Maintain CEU and certification requirements.
- Attend various meetings wihtin the Business Office and practice to gain understanding of overall functions to ensure compliance for billing.
JOB SUMMARY / PURPOSE
Processing credentialing and recredentialing applications accurately and in a timely manner; review files for application completion in compliance with The Joint Commission standards, NCQA standards and Medicare/Medicaid standards.
ESSENTIAL KEY JOB RESPONSIBILITIES
- Process primary verification data during the credentialing and recredentialing of providers.
- Prepare verification letters.
- Maintain database for provider credentialing and recredentialing.
- Contact medical office staffs, licensing agencies and insurance carriers to complete credentialing and recredentialing applications.
- Handle confidential information in an appropriate manner.
- Support OPPE and FPPE processes.
- Performs other duties as assigned to meet the organization`s needs.
Franciscan Medical Group is currently seeking a HIM Rep for our Franciscan Health Information Management team. Flexible work schedule within a fast paced environment with a strong, collaborative team. No weekends, nights or organizationally recognized holidays required.
Performs duties related to the receipt, intake, scanning, indexing, quality control, retrieval, delivery and transfer of patient health and administrative information using an electronic medical records system.
- Scans and indexes medical records into electronic medical records (EMR) system according to established policies and procedures, including accurately entering, directing, and handling patient messaging in EMR.
- Maintains electronic-based medical records and other correspondence according to policy, including faxing, receiving and mailing medical records in accordance with HIPAA and other privacy guidelines; maintains organization of information center and physical charts.
- Accesses/monitors EMR work queue to resolve outstanding matters such as; error correction, chart retrieval, release of information and other health information functions.
- Conducts routine quality audits of scanned and indexed documents to identify discrepancies to the FMG scanning matrix.
Produces routine system reports demonstrating compliance with required quality metrics.
- Performs documentation preparation, filing, and retrieval, procedures per established policies and procedures.
- Exhibits and adheres to CHI Franciscan Health’s Core Values of Reverence, Integrity, Compassion and Excellence.
- Documents or records the visit elements exactly as stated by the practitioner without interjecting his or her own observations or impressions.
- Captures accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter in a timely manner.
- Assists the practitioner in navigating the medial record.
- Responds to various messages as directed by the practitioner.
- Locates information for review (es: previous notes, reports, test results, and lab results)
- Documents information into the medical record as directed by the practitioner.
- Enters information in the electronic health record such as patient history, system review and physical examination, vital signs, procedures and treatments performed by the practitioner, care plan and medication lists, progress of lab, x-ray or other patient evaluation data, and practitioner dictated diagnoses, prescriptions and instructions.
- Researches information requested by the practitioner.
- Must make entries in the electronic health record using their own password/ access for all entries and must clearly include the name of the scribe and a legible signature/electronic signature, the name of the practitioner rendering services, qualifications of each person, and authentication of the scribe, including accurate date and time of service.
- Supports practitioner in care documentation and data retrieval
- Performs other duties as assigned to meet the organization`s needs.
Responsible for advancing clinical practice and improving patient outcomes through the effective integration and utilization of Clinical Information Systems (CIS) in the practice environment. Assist in the planning, design, build, testing, implementation, stabilization, and ongoing evaluation and optimization of clinical information systems.
- Utilize knowledge and skills of informatics with current evidence and clinician input to determine clinical information systems and workflows best suited for end-users.
- Advocate for the clinicians and nurses in the design, build, testing, implementation, evaluation, stabilization, optimization, and upgrading of clinical information systems: a. Assist in developing end-user requirements with the guidance of the senior staff b. Assist in identifying, developing, validating and utilizing forums to solicit input and bring end-users to appropriate content, design of screens and forms, and workflow with end-users, effectively communicating findings.
- Assist in efforts that promote and streamline communication and continuity of clinical and operational practices during declared inter-facility system downtime.
- Assist in the development of best practices that promote the adoption of clinical information systems into clinical practice.
- Participate in the development and maintenance of policies and procedures related to clinical and nursing practice supported by clinical information systems.
- Assist in developing, measuring, and analyzing metrics for efficiency and quality.
- Assist in developing meeting agendas, coordinating content, and disseminating meeting minutes.
- Ensure CIS is designed and consistent with professional standards of clinical practice; effectively support key clinical efforts including, but not limited to quality and or regulatory measures.
- Analyze issues and develop recommendations with senior staff, including escalating issues as needed, completing work order requests in a timely manner and performing follow-up with the customer to ensure satisfactory resolution.
- Assist in carrying out tasks identified in the project plan for all assigned projects.
- Support clinicians in the usage of Clinical Information Systems in order to promote patient safety.
- Additional duties as assigned.
Utilize available tools including Crystal Reports and CACHE to query data from pharmacy electronic systems into meaningful audience-specific reports for use in change management, project management, performance improvement, presentations and publications. This includes conducting complex analytics, statistical analysis, and integrating benchmark data from multiple sources as appropriate. Within Epic Willow, develop and configure inpatient hospital pharmacies using Epic master files including, Pharmacy (PHR), Medication (ERX), Drug Product (NDC), Order Sets (PRL), Medication Panels (OSQ) using CACHE and MUMPS. Expertise in the maintenance of Pyxis ES and Omnicell Med Carousel, which are pharmacy support systems integrated with Epic. Activities in these systems include, end user provisioning, building medications, monitoring medication discrepancies and reconciliation, running various reports and Pyxis ES device health monitoring. Interprets HL7 messages and consults with team members to evaluate interfaces between hardware and software, develop specifications and performance requirements, and resolve end user problems and requests. Perform accurate analysis and effective diagnosis of end user issues. Creates educational materials and detailed presentations for audiences ranging from senior management, department leadership, hospital administration, and staff-at-large. Conducts literature searches and tracking healthcare industry trends, third part reporting requirements and information technology developments to support the performance improvement process. Works and communicates well with medical staff, hospital staff, hospital committees, and other personnel to achieve objectives and enhance clinical efficiency and effectiveness. Design and implement project plans and manage tasks and resources effectively within project scope. Assists in the coordinating and testing of new software installations and application upgrades.
PRN, Day Shift, Saint Joseph Hospital