CLINICAL DOCUMENTATION ANALYST Full Time Days

01 ETCH East Tennessee Children's Hospital Association, Inc.; United States; On-site; USD 42,000 - 63,000; Full time

Job summary

Dolly Parton Children’s Hospital is seeking a Health Information Management professional to ensure complete and accurate medical records. The role involves collaborating with clinical staff to obtain missing information and maintaining regulatory-compliant documentation.

Ideal candidates have an associates degree in Health Information Management or related field, with 2–3 years of experience and preferred RHIT/RHIA certification.

Qualifications

• Associates degree in Health Information Management or related field required.
• Preferred RHIT or RHIA certification; otherwise licensure as RHIT/RHIA preferred.
• 2-3 years of health information management experience preferred.

Responsibilities

• Analyzes inpatient, observation, and surgery records for timely and accurate completion.
• Maintains backlog within 5-7 days of discharge.
• Identifies and updates deficiencies for providers.
• Performs QA on scanned records and rescans completed records within 3 days.
• Reviews dictations and updates deficiency statuses in HIM software.
• Generates and reviews the discharge analysis list bi-monthly.
• Assists physicians with completion of medical records and handling incomplete records.

Skills

Microsoft Word

Outlook

Multiple software programs

Medical terminology

Organizational skills

Time management

Interpersonal skills

Customer service

Education

Associate degree in Health Information Management or related field

Tools

HIM software

Job description

BASIC PURPOSE OF THE JOB

Reviews accuracy and completeness of medical records to assure that all patient documents are maintained in accordance with hospital and regulatory guidelines. Works with clinical staff/physicians to obtain missing information for patient medical records.

JOB REQUIREMENTS

• Supervisory Responsibilities: No Minimum Education: Associates Degree Degree: Health Information Management or related field License/Certification Required: Registered Health Information Technician (Preffered)/Registered Health Information Administrator Minimum Work Experience: 2-3 years experience in Health Information Management preferred

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Proficient in the use of computers with knowledge of Microsoft Word and Outlook
• Ability to maneuver through several computer programs
• Ability to prioritize work
• Knowledge of medical terminology
• Strong organizational and time management skills
• Excellent interpersonal and customer service skills
• Ability to interact with persons of varying backgrounds and education levels

DUTIES AND RESPONSIBILITIES

• Analyzes Inpatient, Observation, and Same Day Surgery records to assure their timely completion and accuracy.
• Maintains analysis back log on Inpatient, Observation, and Same Day Surgery records, on average, within 5-7 days of discharge.
• Accurately identifies, assigns and updates all deficiencies for providers.
• Performs quality assurance (QA) on scanned records for Inpatient, Observation, Same Day Surgery patients.
• Performs rescans of completed medical records within 3 days of completion.
• Audits discharge analysis work list bi-monthly to assure that analysis has been performed on every Inpatient, Observation, Same Day Surgery patient medical record.
• Reviews completed dictations morning and afternoon; assigns and removes dictation deficiencies accurately and timely in HIM software.
• Completes the electronic signature rejection report daily.
• Sends written notifications for any impending delinquent Deficiencies to medical staff department heads, and Chief of Staff prior to creating the No Admit/No Clinical Privileges List.
• Creates the No Admit/No Clinical Privileges List on the first of the month according to regulatory and hospital guidelines; monitors and updates the No Admit/No Clinical Privileges list daily.
• Assists physicians/practitioners with completion of medical records to include taking/picking up incomplete records to and from the surgery lounge.
• Assists co-workers as needed in a courteous and professional manner.
• Utilizes hospital resources and time respectfully and accountably.

PHYSICAL REQUIREMENTS

Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position. Medium lifting, pushing and pulling is required for 20-50 lbs occasionally, 10-20 pounds frequently and 10 lbs constantly to move objects. Sudden emergency situations have the potential for exposure for lifting or moving of up to 100 lbs. Frequent bending, walking, sitting, squatting, reaching, and standing are required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference everyday. At Dolly Parton Children’s Hospital, care is at the CORE of who we are. We are comprised of team members who live out our core values of Compassion, Ownership, Respect, and Excellence. We support each other by fostering a culture of team engagement that creates moments that matter – every interaction, every time. Compassion – We imagine what others are going through, work to alleviate suffering, and create joy whenever possible. Ownership – We take pride in our work, act with integrity, and feel personal responsibility for achieving our mission. Respect – We listen, understand, and communicate openly and politely. We recognize our diverse strengths. Excellence – We set high standards for performance in delivering the safest patient care. We give extraordinary and meaningful experiences to our patients, their families, team members, and the community we serve.