Chart Clerk Job Description Sample
Department: CH101_65000 Health Information Management
Expected Weekly Hours: 20
Shift: Day Shift
Job Description Details: Part Time Days
Retrieval of heath care clinical documents from the hospital and ancillary heath care areas.
Performs scanning to ensure heath care clinical documents are scanned timely and accurately into the patients' Electronic Health Record. Performs document quality control to ensure the integrity, completeness, and legibility of the scanned health care clinical documents in the EPIC Electronic Health Record. Responsible for releasing medical record information, both electronic and paper, in response to requests from internal and external requesters.
Responsible for qualitative analysis of documentation and deficiency analysis within the medical record, checks physicians' incomplete deficiencies and assists in completion of said deficiencies to ensure compliance with regulatory agencies and Medical Staff Bylaws. Education- High school graduate. Prefer someone with previous experience in the healthcare field performing quality control of scanned health care clinical documents and/or scanning of health care clinical documents Trinity Health's Commitment to Diversity and Inclusion Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states.
Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.
Trinity Health offers rewarding careers in a community environment with all the advantages of working at one of the nation's largest health systems. We provide high-quality, people-centered care in 22 states through our network of hospitals, facilities, community-based services, and continuing care locations - including home care, hospice, Program of All Inclusive Care for the Elderly (PACE), and senior living facilities. If you are looking for a rewarding clinical or administrative position, you'll find exceptional career possibilities, opportunities for advancement and a job with meaning at Trinity Health.
Trinity Health employs more than 131,000 colleagues across 22 states. We honor and embrace a diverse representation of people, ideas and backgrounds. Our dedication to diversity is evident in our commitment to training, education, recruitment, retention and development, as well as community partnerships and supplier diversity.
Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences and health practices of the communities we serve and to apply that knowledge to produce positive outcomes. We recognize that each of us has a different way of thinking and perceiving our world, and that our differences not only serve to unite us, but also lead to innovative solutions.
Chart Management Supervisor
Plans, analyzes, coordinates, controls, and supervises all activities of chart management and medical transcription staff related to release of health information processes.
Coordinates functions and needs of clinicians, ancillary departments, and other organizational units to facilitate chart management and dictation and transcription system processes.
Directs workflow to ensure timely transcribed health information and timely chart management processes for clinicians and other staff.
Educates personnel and serves as liaison to Health Information Management with other organization units within Region concerning chart management and dictation and transcription of medical reports.
Develops, implements, and monitors tracking system for chart management and documentation as well as for dictated and transcribed reports.
Administers process for receiving, tracking, investigating, and resolving complaints concerning chart management and documentation as well as dictation and transcription policies and procedures in coordination and collaboration with legal counsel and others.
Plans, develops, and conducts training to orient physicians and staff on policies, procedures and methods of appropriate chart management, documentation and dictation of patient's health information.
Acts as chart management, dictation and transcription resource to peripheral clinics and departments.
Serves as system administrator for all dictation/transcription systems, mainframe and PC applications. Analyzes problems and formulates solutions with providers, department managers, and other related personnel and outside vendors. Maintains systems operations at maximum performance with assistance from Information Services and Telecommunications experts and vendors. Participates in testing upgrades and systems implementations with Information Services and Telecommunications experts and vendors. Evaluates new technology in dictation/transcription systems. Recommends procurement as deemed appropriate to enhance department service levels. Arranges for maintenance contracts on equipment as necessary. Interacts with vendors seeking competitive prices and equipment for department. Ensures consistency of medical transcription, chart management and documentation and confidentiality policies, procedures and documents with KP policies, statutes, accreditation guidelines and professional ethics.
Develops and implements plans/projects to improve operational efficiency and effectiveness. Monitors and reports status and progress to manager. Researches and analyzes data to troubleshoot problems in areas of efficiency and productivity. Develops and implements solutions; reports to management. Performs initial and periodic risk assessments. Conducts related ongoing compliance monitoring activities in coordination with compliance and operational assessment functions. Develops, reviews, and revises release forms as needed in compliance with current legal and accrediting standards.
Hires, trains, supervises, counsels, disciplines, and terminates assigned staff as appropriate.
- Communicates goals, objectives, accountabilities, priorities, and authority parameters to assigned staff.
Minimum one (1) year medical transcription experience and chart management experience. Education
Associate's Degree in health-related field. License, Certification, Registration
- Valid driver's license. Additional
Some knowledge of automated dictation and transcription systems and chart management.
Demonstrated knowledge of and skill in an electronic medical records system.
Demonstrated knowledge of and skill in project management, problem solving, oral communication, written communication.
- Demonstrated knowledge of and skill in word processing, spreadsheet, and database PC applications.
Experience in a Medical Transcription setting that included participation in quality control/improvement activities.
Supervisory/lead or project management experience.
Certified Medical Transcriptionist (CMT) by American Association of Medical Transcriptionists.
Certified Registered Health Information Technician (RHIT) or Administrator (RHIA) by the American Health Information Management Association (AHIMA).
Bachelor's degree in Health Information Management or related field. COMPANY: KAISER TITLE: Chart Management Supervisor LOCATION: Honolulu, Hawaii REQNUMBER: 503352 External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
RN - HCC Chart Reviewer
DaVita Health Solutions is a subsidiary of DaVita Inc., a Fortune 500® company and leading provider of integrated health and kidney care services. DaVita Health Solutions offers payors and risk-bearing organizations a suite of home- and outpatient-based care programs to address the needs of their high-risk, medically complex patient populations. Its programs include physician-led house calls that extend primary care into the home with a heavy focus on palliative care and behavioral health, advanced post-acute care with employed SNFists and integrated kidney care. DaVita Health Solutions leverages more than 15 years of experience in managing high-risk patients under at-risk and shared savings arrangements. Through its medical group, DaVita currently operates house calls programs that serve more than 12,000 patients in five markets, in partnership with 4,000 independent and employed primary care physicians. Through its integrated kidney care division, DaVita manages the total care for more than 20,000 renal patients, of which nearly 7,000 are under at-risk arrangements, in 16 markets and several national programs. Be different. Do what you love. The Chart Reviewer (CR) is responsible for performing thorough clinical reviews of outpatient, inpatient, and skilled nursing charts. The primary purpose of the reviews is to inform clinicians of potential inferred and/or missing diagnoses not previously identified. The chart reviewer will also aid in the education and discovery of opportunities for improved coding and documentation. Essential functions of the Chart Reviewer role will include:
Review and audit all portions of the medical record including but not limited to past medical and surgical history, medication lists, specialty and primary care notes, imaging, hospital records, labs and vital signs, etc.
Review and audit all current and outstanding diagnoses for patients; the CR documents newly found diagnoses and reports findings internally.
Provides debriefings with clinicians, using all required reports including newly suggested chart reviewed diagnoses.
Recommends ongoing chart review process to ensure continued high standards in coding and documentation
Aid in the development and implementation of processes for ongoing coding and documentation education for providers.
Attends courses as needed to improve knowledge of coding and documentation
Collaborate with other clinical and administrative staff in a positive, constructive manner
Use, protect, and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
Perform other duties and responsibilities as assigned or requested Qualifications
Current RN license in Pennsylvania; additional license in New Jersey preferred
Bachelor's Degree in Nursing required
Coder certification preferred + 5 years of General Clinical experience required, MediCare Advantage experience preferred
Two years of clinical coding claims review and utilization experience with strong attention to detail and a high level of accuracy
Knowledge of CMS-HCC/RAF model, coding and guidelines along with ICD-10 and CPT guidelines
Knowledge of health plan and regulatory requirements
Experience with at least one EMR and chart abstraction tools
Additional Quality Assurance auditing and Chart Review experience preferred
Commitment to act and speak in accordance with the DaVita, Inc. mission and values
Coordinator, Chart Completion (Westchester)
001IGK Job Category
Administers the physician suspension process; including sending notices to and calling physicians, preparing suspension lists, and communicating with the President, Medical Director and appropriate Vice Presidents.
Monitors the chart completion process and assists physicians with chart completion. Responsible for maintaining an acceptable level of incomplete records which according to New York State DOH, “all records are to be completed within 30 days of discharge” and JCAHO standards “50% of the average monthly discharges to be incomplete past 30 days”.
Maintains the automated chart deficiency tracking system by monitoring and working the deficiency work list to resolve all “re-opened, rejected, overdue, late, invalid signature, document received” deficiencies.
High school diploma or GED required.
Knowledge of Medical Terminology, Anatomy & Physiology required.
Two (2) years related experience in Health Information Management (HIM) department is required.
Ability to read, write and communicate in English required.
Registered Health Information Technician (RHIT)/ Registered Health Information Administrator (RHIA) certification preferred.
RN / LPN Clinical Chart Review Team
Med-Scribe, Inc. Healthcare Recruiters is presently searching to add staff to a temporary traveling Chart Review Team to fill full time positions! This is a temporary position in Buffalo, NY projected to last 3-4 months beginning January 2018. Spots fill up fast so waste no time – apply today!!
This is a traveling position and all reviews are performed in provider’s office as scheduled in and around the Buffalo area. RN’s $30/hour and LPN’s $25/hour plus mileage!
Job duties: The job would revolve around performing on-site chart reviews at provider offices. The nurse in this role will be trained to capture the diagnostic profiles of targeted plan members and record on an iPad provided by the client. MA plans are required by law to provide diagnostic profiles to the Centers of Medicare and Medicaid in order to anticipate the complexity of care and acuity levels of their membership. In order to do so, we recruit Nurses for their skill set in charting to accurately capture the diagnostic profiles of the targeted members.
Hours: Monday to Friday 4 to 5 days per week between the hours of 8am to 5pm.
Requirements include the ability to review medical records and abstract predefined data, and collect information as prescribed by the project. Must be able to travel throughout Buffalo, NY. Current RN NY License in good standing and a clean driving record with reliable transportation as well as a cell phone is required for this position. RN’s and LPN’s with Clinical chart review experience preferred. LPN’s with geriatric and or chronic conditions experience is required.
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To be considered, please visit our website at www.medscribe.com to complete an online application and reference job number #111317.
Med-Scribe, Inc. is an Equal Opportunity Employer and our policy is to provide equal opportunity to all persons. No employee or applicant for employment will be discriminated against because of race, color, religion, sex, national origin, disability, sexual orientation, gender identity, gender expression, veteran status or any other Federal or State legally-protected classes. Women, minorities, veterans, and individuals with disabilities are encouraged to apply. Any person with a disability needing special accommodations to the application process, please email us through our website at www.medscribe.com.
Medical Chart Review Specialist
The Medical Chart Review Specialist is responsible for conducting a medical review of potentially transplantable donor charts. The individual needs to have solid written and verbal communication skills, be able to multi-task, and have strong analytical skills.
Responsibilities of the position include, but are not limited to:
- Provide follow up on Donor Risk Assessment Interviews, autopsy reports, physician and medical records
- Consult with attending physician, Medical Director and Infectious disease Specialist to determine tissue suitability
- Perform donor file status reviews to ensure that all pertinent documentation has been included
The successful candidate will be a highly motivated professional with these qualifications:
- RN or BS, preferred or equivalent experience
- Ability to interface with peers and hospital personnel on assignments
- Excellent telephone, communication, and customer service skills
- Basic knowledge of patient confidentiality laws
- Position will require weekend and evening work on occasion
Competitive compensation and benefits.
Our mission is about the restoration of sight, through timely recovery, excellent processing and efficient distribution of the highest quality eye tissue for transplantation, ophthalmic research and training. We are honored to have a strong history of being one of the top eye banks in the United States and continue to strive towards excellence to bring clarity to as many Alabamians as we can.
Great work starts with great people. Great people who are passionate about what they do. We all have a clear vision of what our motivation is and why we come to work each day. Each day, knowing that someone’s hope was restored through their sight because of us is the best feeling. Combine that with an amazing work environment, who wouldn’t want to work with us?
The main benefit of working at AEB is knowing that we are making an impact on people's lives, helping restore their sight and purpose in life. The other perks start with a competitive salary and one of the more generous benefits packages around including Blue Cross Blue Shield Health and Dental Insurance, short and long-term disability, flexible spending account & 401k with generous employer match.
Sr. Director, Chart Capture & Coding
PopHealthCare is currently seeking a Full-timeSenior Director, Chart Capture & Coding. This position is based in our corporate office in Franklin, TN. At PopHealthCare, our mission is simple – help higher risk individuals live healthier lives (www.pophealthcare.com). We are bold innovators, dedicated to making a difference and we hire wicked smart people! We need sharp and nimble people to join our growing team!
As a Senior Director, Chart Capture & Coding, this position will be part of a team responsible for the efficient retrieval and accurate coding of medical records for purposes of documenting risk-adjustment-eligible diagnoses. The Senior Director is expected to provide strategic leadership in the planning of Department capacity to meet client demands for medical record procurement and coding. This individual needs to be a visionary, problem solver, results-oriented and an innovator. It is part of the Risk Adjustment Operations area, which provides a full array of risk-adjustment services to our clients in the Medicare Advantage and Affordable Care Act markets. The Senior Director is also expected to be a key contributor in corporate strategic planning for risk-adjustment services to clients and the internal capability development for improvements in the quality and efficiency of those services.
Position Essential Functions:
- Set and implement the short and long-term vision and strategy, in alignment with overall corporate goals and objectives.
- Provides strategic leadership to influence corporate strategy relative to risk adjustment and ACA.
- Coordinates large scale issue resolution for multiple internal and external stakeholders.
- Collaborate and coordinate with internal and external stakeholder to meet expectations.
- Have accountability for overall department production and quality.
- Manage external vendors, including staffing agencies and chart retrieval services, to meet performance standards of production, quality and compliance.
- Lead the department to ensure adherence with all applicable governing regulations and contractual arrangements.
- Serves as strategic planner and first line of defense in developing ongoing staffing requirements.
- Work with the managers to develop goals and policies that continually challenges managers and staff to evaluate processes and capabilities to further improve efficiencies.
- Work with the Manager of Compliance to develop and execute quality assurance programs.
- Ability to leverage analytics with operations and reporting.
- Develop and manage administrative budget for department.
- Bachelor’s degree, or equivalent work experience.
- 7+ years related work experience or combination of transferrable experience and education in the areas of federal risk adjustment and/or coding operations.
- Minimum of 5 years in a managerial/leadership position.
- Knowledge of medical record coding.
- CPC and/or CRC preferred.
- Ability to communicate effectively.
- Strong analytical, problem solving and research skills
Crucial to that mission is our capacity to re engineer the system so that improved patient care and improved cost management can exist in harmony. We believe that sophisticated analytics coupled with properly funded, compassionate clinical care can improve the health of populations, one person at a time.
Over our ten years in business, PopHealthCare has analyzed data for millions of members, reviewed tens of millions of medical records, and consistently delivered high ROIs for our dozens of loyal clients serving some of the most expensive, most vulnerable populations in the country.
Our executive leadership and management teams have developed and deployed groundbreaking programs in high-risk population care that have redefined the care delivery model, proving that rapid and large reductions in costs and utilization are achievable through timely face-to-face delivery of preventive care, member support and provider communications.
Registered Nurse Chart Reviewer
- Registered Nurse, Licensed Practical Nurse, Nurse Practitioner - geriatric experience is preferred but not required
- Seasonal - Jan, Feb, Mar, April 2018
- Availability M-F 3-5 days per week
- Computer literacy required
- Pay Rate $30/hour
- Mileage: Time Paid and Miles Reimbursed
- Interviews starting immediately
The Clinical Documentation Review Nurse will be responsible for reviewing assigned medical records, and should be fully computer literate. The successful candidate will be able to discern diagnoses and treatments from documentation available. Chart Reviewers will be needed throughout Western New York and travel will be involved. Candidates should have 3 years clinical experience. If you are interested, please send your Resume to: JThompson@INCnursing.com or call Judy Thompson at 716-655-8776, ext. 324.
Deficient Chart Supervisor
This is a great opportunity to work with one of the largest ED coding and billing companies in the country, providing complete full service, end-to-end coding and billing for millions of ED visits annually in across the country. There are tremendous growth opportunities as company continues to expand their business.The Deficient Chart Specialist is responsible for processing medical records that have been reviewed by Coders and found to be un-codeable.Duties and
Search in medical records on line for information
Assign cases to coders
Prepare and check unable to code charts
Send UAC lists and charts to clients
Search laser fiche for specific charts To perform this job successfully, an individual must be able to perform each duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities perform the duties.
High School diploma or equivalent combination of education and experience required
One to two years related experience preferred
Prior word processing, spreadsheet, and internet software experience including proficiency with MS Excel and MS * Word required Kforce is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.
Minimum Compensation:0.00Maximum Compensation:*0.00
Field-Based Chart Reviewer/Collector (Sdc)
Inovalon is the nation’s largest medical record reviewer. To accomplish this, Inovalon utilizes Medical Assistants, Certified Nursing Assistants, and Medical Clerks to go to physician offices, clinics, hospitals, and other clinical facilities to obtain and/or review medical data. Inovalon does these reviews in all 50 states around the nation. Inovalon is currently recruiting Medical Assistants, Certified Nursing Assistants, and Medical Clerks to perform medical record reviews in the field. Inovalon offers highly competitive hourly compensation as well as compensation for mileage traveled. Inovalon reviewers are provided with a laptop and full abstraction and technology training. Both part-time and full-time hours are available.
Accurately and efficiently conduct medical record review/abstraction services;
Scan relevant components of the medical record to support reviews performed;
Electronically download review assignments to the laptop and data collection tool; daily upload completed assignments and scanned medical records;
Participate in required training;
Complete quality, accuracy and inter-rater reliability testing as requested in a timely manner;
Communicate effectively and professionally with care provider offices, clinics, hospitals, other clinical facilities and Inovalon staff;
Travel to medical facilities in specified area of region from home to complete review services as assigned by Inovalon;
Represent Inovalon with medical facility staff; and
Abide by all HIPAA and associated patient confidentiality requirements.
Medical Assistant or Certified Nursing Assistant or Medical Clerk;
Clinical experience; prefer experience in performing chart abstractions;
Ability to manage and meet deadlines;
Computer literate and detail oriented;
Professionally skilled in verbal and written communication;
Available to perform reviews no less than 24 hours a week;
Must be willing to travel; and
Must have high speed internet access. Inovalon provides equal employment opportunities (EEO) to all employees and applicants for employment. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or protected veteran status and will not be discriminated against on the basis of disability. Requisition ID: 2017-7603 External Company Name: Inovalon, Inc. External Company URL: www.inovalon.com
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