Summary

Department: CLINICAL SUPPORT SERV

Shift timings: 08:30-17:00 Monday to friday 5 Days/8 Hours

Per week: 40 Hours

Maintains all documentation of patient records including but not limited to admissions service provided and discharges. Manages processes for monitoring the accuracy and completeness of the EMR and ensuring the security and confidentiality of the records through the use of the required safe guards. Knowledgeable in all aspects of Agency policy and services.

Requirements

Experience: 3 years

Skills

• Clerical Assistant

Responsibilities

Prints 485s physician orders and other clinical documentation for both Medical Surgical and Hospice Sends documentation/orders to physicians via fax mailings and or/uploads into Doc Center Checks in received signed orders in Document Manager Tracks to ensure signed physician orders are received by the agency according to standard (14-30 days) (Runs Outstanding report tracking. Runs Incomplete report 5 day window of start of care date for Certification/recertification report CTIs Hospice Certifications/recertifications Hospice Face to Face Follows up with the physician office for orders not received within agency guideline and documents call in episode note. Notifies coordinator after two attempts to obtain orders if unsuccessful. Runs Outstanding Report for both Med Surgical and Hospice documents. Identifies any changes/discrepancies in physician demographics i.e. address phone number. Notifies manager of finance to update physicians demographics Identifies discrepancies on all orders of start of care date diagnosis codes verification of data corruption of clinicians authorship Makes correction to the system and documents changes in episode note. Obtains documentation from medical record as needed. Problem solves incorrect or incomplete information to ensure receipt of signed orders. Runs and reviews system reports to manage document tracking. Documents any privacy issues according to agency guidelines. Identifies trends related to incomplete/inaccurate documents and reports same to coordinator. Reviews designated vendor reports( McBee) report to process certifications recertifications Notifies clinician to lock documents Receives faxes and mail from physicians offices and any clinical paperwork that pertains to medical records Sorts received information. Obtains correct medical record. Scans documentation into correct medical record episode (admission identifier) Review MOLST forms for completeness and send to provider for signature Send IDG Notes to designated provider by fax mail or portal Submits designated record requests to vendor( Sharecare) for processing. Documents the required elements in the EMR Retrieves required documents for regulatory and other agencies as needed Check that consents are on file for all patients. Notifies admit clinician and manager if consent is missing. Cross train to answer reception calls from front desk and overhead telephone bell assistance Assists in development of agency medical records education Assist in the development of agency processes and procedures. Requirements: High school diploma or equivalent; with one year of related experience preferred. Medical terminology basic/intermediate skills using Microsoft Office applications; specifically: Excel Word Access and Outlook.