Job Description: Clinical Documentation Analyst

Job TitleClinical Documentation AnalystReports ToHIM ManagerDepartmentHealth Information ManagementFLSA StatusNonexempt

Summary

Responsible for analyzation of records, releasing copies of medical records in accordance with hospital policy and Federal and State laws, scanning, and uploading documentation into medical records. 

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and /or ability required.

• Performs analysis on all charts to assure documentation is complete.
• Completes closed chart review, reviews/investigates charges, contacts appropriate departments for additions/corrections.
• Reviews each Inpatient charts for required Care Plans prior to discharge from hospital, contacts appropriate departments for additions/corrections.
• Contacts Provider if dictation is needed while patient is hospitalized.
• Reviews same day encounters, and combines per EMR standard guidelines.
• Combines Persons or Encounters within EMR.
• Performs Quarterly Clinic Review Process.
• Performs Quarterly Hospital Peer Review, uploads redacted PHI charts for Peer Review process to third party reviewer.
• Gathers data from multiple departments and runs appropriate reports to compile the monthly statistical and utilization review dashboards.
• Gathers data to complete Birth Defect Registry per state requirements.
• Gathers data to complete Cancer Registry per state requirements.
• Transcribes and places Provider dictations into the correct Note Type into EMR .
• Maintains passwords in dictation system for any new/exisiting Provider requiring access. 
• Maintains a log and destroys records according to policy and state regulations.
• Contact person for funeral homes and assures timely Provider completion of online death certificates.
• Utilizes NESIIS (Nebraska State Immunization Information Sustem) for immunizations.
• Accesses ENARSIS to retrieve EMS documentation to add to EMR.
• Scans/uploads appropriate incoming documents into EMR, sending to appropriate Provider for review.
• Sorts and distributes inter-department mail. 
• Answers incoming Registration and HIM phone calls.
• Schedules patients for appointments.
• Assists patients in obtaining access to patient portal.
• Assists all departments throughout Saunders Medical Center in locating needed reports and records.
• Uploads request letters to 3rd party ROI vendor.
• Fulfills urgent ROI requests, completing necessary HIPAA Right to Accounting documentation according to state and federal regulations.
• Upholds HIPAA and confidentiality regulations of record access and review. Alerts HIM Manager of unusual request for records.
• Assists with ACO care gaps and submitting documentation.
• Trains SMC Staff on accessing legacy documents in data repository. 
• Responsible for training of new staff and cross training amongst current staff.
• Problem solves electronic health record issues and opens support tickets with EMR vendor, if needed. This includes testing fixes and new solutions.
• Uses department computers in an appropriate , efficient manner.
• Participates in quarterly quality management studies.
• Participates in all quality, safety, security, and infection control programs that are mandatory as well as those required and provided by the department.
• Participates in monthly SMC Steering Committee Meetings.
• Ensures electronic Policy and Procedures are updated yearly.
• Ensures confidentiality of patient information.
• Upholds confidentiality and HIPAA compliance at all times and report violations to the Privacy Officer. 
• Serves on HIPAA Committee as requested
• Assists with completing HIPAA Investigation forms, may include interviewing SMC staff, if required.
• Understands and complies with the requirements of the Saunders Medical Centers Compliance Program, including but not limited to Code of Conduct, the Compliance Policy, all Saunders Medical Center-wide policy and as requested by the Manager.
•  Participates in all education and training programs regarding compliance as required by Saunders Medical Center policy and as requested by the Manager.
• Demonstrates personal traits of high-level commitment, motivation and energy, team orientation, professionalism, trust, personal honesty and integrity, placing others in a place of high value by treating them with dignity and respect.
• Other duties as assigned by the Manager.

 Supervisory Responsibilities

None. 

Disclosure Statement

The above statements reflect the general details considered necessary to describe the essential functions of the job as identified, and shall not be considered as a detailed description of all work requirements that may be inherent in the position.

Education and/or Experience

High school diploma or equivalent.
Experience in medical field as it relates to medical records.
Proficient in computer and typing skills.

Certificates Licenses, Registrations

None required.

Language Skills

Must be able to read, write and follow written and oral instructions and possess positive skills in communication. Ability to deal tactfully with personnel, patients, visitors, and the general public.

Mathematical Skills

Ability to calculate at the level necessary to perform essential duties of the position.

Reasoning Ability

Ability to make independent decisions when circumstances warrant such action. Ability to interpret a variety of instructions furnished in oral, written, diagram or schedule form.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee must sit frequently and spend long periods of time examining documents. The employee must stand, reach with arms and hands and occasionally lift, push or pull 50 pounds. The employee must occasionally walk and climb or balance.

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 of this position. Attendance is essential and required for a successful working environment.