HIS QA Reviewer

Summary :

Under the supervision of the HIM Manager is responsible for quality review of completed medical record chart determines accuracy and commits EHR as final. Serves as a resource for the transcription process. Responsible for the operations of the transcription area processing of all transcribed documents and related services in conjunction with the outside medical transcription service.

Responsibilities :

Perform Quality review of completed records in the electronic medical record (Inpatient Observation Ambulatory Surgery and Emergency Department records) to determine if ready for final release of completed record.

Review all content of record including transcribed reports physician orders consultation reports test results consent forms operative reports progress notes etc. to ensure compliance with all Joint Commission State Federal and Lifespan regulations / requirements.

Commitdocuments scanned to OnBase / Epic

Receive transcribed reports from the vendor. Verify receipt of reports utilizing dictation system database. Process all transcribed reports from the outside agency for distribution to appropriate areas in a timely manner. Ensure copies are prepared and distributed to appropriate personnel. Flag reports requiring further documentation from the physician. Photocopy print fax and forward reports for filing.

Serves as back up in the absence of Management to ensure that the transcription center equipment is properly maintained and serviced as required. Distribute portable dictation sets to surgical services and other dictation system user departments as necessary when system interruptions occur notifying appropriate personnel of the same.

Single import transcribed reports that fail to come over from electronic dictation / transcription system

Set up new physicians in the dictation system in conjunction with the IT Help Desk and Medical Staff Services. Provide training to medical staff on the use of the dictation process / equipment.

Perform other duties as assigned.

Other information : BASIC KNOWLEDGE :

High school level of knowledge plus formal program in medical terminology.

Must have excellent command of medical terminology

Demonstrate complete working knowledge of current medical terminology including anatomy physiology disease process pharmacology laboratory values diagnostic testing and medical / surgical procedures to effectively review returned transcribed material assess accuracy and completeness requiring oral and manual abilities and experience operating dictation / transcription equipment.

Working knowledge of computer software especially electronic health records patient and provider databases medical record tracking systems word processing Microsoft Word Excel.

Working knowledge of speech recognition systems.

Analytical and organizational skills to effectively review completeness and accuracy of reports and invoices and to prepare and maintain related records.

Math skills necessary for report generation and analysis.

Interpersonal skills necessary to effectively interact with others including physicians within and outside the hospital to explain procedures and resolve problems etc.

EXPERIENCE :

Two years or more experience in Electronic Medical Record review function and or equivalent training EPIC preferred.

Normal office environment with little discomfort due to noise heat dust etc.

Regularly experience mental / visual fatigue from constant review of reports typing assignments.

Work requires nearly constant coordination of visual and aural effort.