Medical Records Auditor

General Purpose

The primary purpose of your job position is to audit multiple facility medical records and health information systems with current federal and state guidelines as well as with facility established policies and procedures.

Essential Duties

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these

are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from

the position if the work is similar, related, or is an essential function of the position.

Administrative Functions

· Receive and follow work schedule/instructions from your supervisor.

· Coordinate on developing a standardized Medical Records Guide defining which legal documents should be uploaded and maintained in the EHR (PCC)

· Provide input/recommendations on timeline for documents to be uploaded into PCC.

· Develop the baseline for the standard order of a "hard", non-EHR Chart.

· Audit facility patient records for compliance with federal and state guidelines.

*Includes audits to support key PDPM financial drivers.

*Includes audits to support Skilled Nursing Charting and Case Mix Groups

*Includes audits to support UB04 charges.

· Develop templates that facilities can utilize to self-monitor.

· Suggest processes facilities may use to improve compliance with medical records protocols.

· Develop and maintain good working rapport with all facility and therapy compliance teams. .

· Retrieve medical records and deliver as required.

· Become proficient with PCC (EMR).

· Alert facility personnel that key documents are incomplete or missing.

· Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed before chart is closed.

· Maintain spreadsheets on facility nursing audit trends for deficient areas and monitors improvement.

· Issue monthly reports covering audit results to Lead Medical Records Auditor

· Verify and support various Triple Checks monthly.

· Will consult with Regional Medical Records Consultants as appropriate.

· Provide facility assistance with Medical Diagnosis coding.

· Coordinate with EMR Team for additional audits or facility oversight.

· Protect resident health information and promptly report suspected or known violations.

· Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this

position.

Committee Functions

· Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.

Personnel Functions

· Report known or suspected incidents of fraud to Director of QA and Compliance.

· Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.

Staff Development

· Attend and participate in mandatory facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.). · Attend and participate in workshops, seminars, etc., as approved.

Safety and Sanitation

· Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately. Equipment and Supply Functions

· Report equipment malfunctions or breakdowns to your supervisor as soon as possible.

· Ensure supplies have been replenished in work areas as necessary.

· Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.

Budget and Planning Functions

· Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

Supervisory Requirements

As Medical Records Auditor, you are delegated the administrative authority, responsibility, and accountability necessary

for carrying out your assigned duties.

Qualification

Education and/or Experience

Must possess, as a minimum, a high school diploma or GED. Must be able to type a minimum of 45 words per minute and use dictation equipment. A working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required. On-the-job training provided in medical record and health information system procedures. Must be knowledgeable of medical terminology. Be knowledgeable in computers, data retrieval, input and output functions, etc.

Language Skills

Must be able to read, write, speak, and understand the English language. Ability to read technical procedures.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability

Must possess the ability to make independent decisions when circumstances warrant such action.

Must possess the ability to deal tactfully with personnel, residents, visitors and the general public. Must possess the ability to work harmoniously with other personnel. Must possess the ability to minimize waste of supplies, misuse of equipment, etc. Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices. Be able to follow written and oral instructions. Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical Demands

Must be able to move intermittently throughout the workday.

Must be able to speak and write the English language in an understandable manner.

Must be able to cope with the mental and emotional stress of the position.

Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements

of this position can be fully met.

Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel.

Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical

examination.

Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull,

move, and/or carry such weight a minimum distance of 50 feet.

May be necessary to assist in the evacuation of residents during emergency situations.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the

essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the

essential functions.

Works in office areas as well as throughout the facility.

Moves intermittently during working hours.

Is subject to frequent interruptions.

Works beyond normal working hours, weekends and holidays and on other shifts/positions as necessary.

Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).

Attends and participates in continuing educational programs.

Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust,

disinfectants, tobacco smoke, and other air contaminants.

Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

Communicates with nursing personnel, and other department personnel.

Is subject to hostile and emotionally upset residents, family members, personnel, visitors, etc.

Is involved with residents, family members, personnel, visitors, government agencies and personnel, etc., under all conditions

and circumstances.

May be subject to the handling of and exposure to hazardous chemicals.