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Aurora Health Care is seeking a Records Specialist to accurately upload and index outside records into the EHR, routing to clinicians as appropriate. You will create or select patient, encounter, and/or order with correct document type and description.
Responsibilities include integrating internal and external clinical documentation, identifying missing items, and ensuring chart completeness per HIM procedures and regulatory standards.
Accurately upload/Index outside records using applicable software, routing documentation to the clinician asappropriate. Creates or selects theappropriate patient, encounter, and/or order while assigning the correct document type and description when indexing into the EHR.
Accurately upload/Index outside records using applicable software, routing documentation to the clinician asappropriate. Creates or selects theappropriate patient, encounter, and/or order while assigning the correct document type and description when indexing into the EHR.
Incorporates internal and external clinical documentation from various electronic and paper sources via applicable software work queues, rounding,eDeliveryor importing into the EHR according to HIM procedures while meeting established benchmarks for quality, accuracy, and productivity.Applies knowledge of medical terminology and nomenclature to accuratelyidentifydocumentation needs based on patient service areas and level of service provided.
Analyzes the content of the medical record for missing documentation and signatures and assign/edit medical record deficiencies by the responsible provider into the chart management system according to State and Federal regulations, such as Det Norski Veritas (DNV) or The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), all Medical Staff Bylaws and organizational policies.Provides support and education to cliniciansregardingrecordcompletionactivities.
Applies knowledge of medical terminology and nomenclature to accuratelyidentifydocumentation needs based on patient service areas and level of service provided.
Collaborates with Data integrity or other functional areas to ensure errors in documentation discovered are communicated for Chart Correction. Notifiesappropriate leadershipfor quality review and privacy investigation.
Ensures clarity, legibility, and position of the scanned documents are readable by the end-user orindicatesbestquality.
Serves as point of contact for recordcompletionsupport for clinicians and other providers.
None Required.
High School Graduate or Equivalent
Typically requires 0-1 years of experiencein healthcare.
Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, OnBase,Solarity, Microsoft Office, and legacy archives, and electronic communication and meeting platforms such as Teams.
High attention to detail and accuracy with frequent interruptions.
Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints.
Ability to work independently and make decisions with minimal supervision whilemaintainingquality and productivity standards.
Works collaboratively in a diverse team environment with openness and respect to learn, create and problem solve.
Ability to adapt to a fast-paced environment and transition to switching tasks without issue whilemaintainingquality and accuracy.
Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success.
Strong interpersonal and communication skills.
Ability to safeguard protected health information (PHI) and basic knowledge of HIPAA.
Operates all equipment necessary to perform the job.
Exposed to a normal office environment.
Sits most of the workday.
Ability to perform repetitive functions and hand movements in a normal office environment
All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
This job description in no way states or implies that these are the only responsibilities to be performed by an employee occupying this job or position. Employees must follow any other job-related instructions and perform any other job-related duties requested by their leaders.