JOB SUMMARY: Analyzes clinical documentation for accuracy and timely completion with minimal guidance. Communicates with providers to ensure completion of clinical documentation in accordance with health record policies and standards. Performs specialized health information activities to organize, maintain and retrieve the clinical and administrative documentation.
Prepares and organizes patients' medical information for inclusion in the electronic health record.
Completes quality review of document images for adherence to document management and regulatory standards.
Reviews clinical documentation for signature, date and time.
Assigns incomplete documentation tasks to providers and follow up for completion.
The responsibilities listed are a general overview of the position and additional duties may be assigned.
MEDICAL RECORDS MANAGEMENT (INTERMEDIATE):- Knowledge of how and where to store and maintain basic records associated with job assignments.
DATABASE KNOWLEDGE (INTERMEDIATE):- Knowledge and understanding of a database and how data is organized so that its contents can easily be accessed, managed, and updated.
CRITICAL THINKING (NOVICE):- The objective analysis and evaluation of an issue in order to form a judgment.
DOCUMENT AUDITING (INTERMEDIATE):- Auditing is conducting an independent review and examination of records and activities in order to test the adequacy and effectiveness of procedures, policies, standards, rules, capabilities and other aspects to ensure compliance with established policy and operational procedures, and to recommend any necessary changes.
COMPLIANCE (NOVICE):- Understanding the rules, regulations, sanctions and other statutory requirements, guidelines and instructions relating to governing bodies and organizations, both internally and externally.
QUALITY ASSURANCE (NOVICE):- Understands the goal of increasing organizational productivity and individual performance by making the products and services within your work assignments more efficient and more effective.
Organizational Impact: Performs non-routine tasks that significantly impact team's performance with minimal guidance.
Problem Solving/ Complexity of work: Conducts research and analysis to solve some non-routine problems.
Breadth of Knowledge: Applies broad job knowledge and has basic job skills in other areas.
Team Interaction: Provides informal guidance and support to less experienced team members.
Vanderbilt University Medical Center is a comprehensive health care facility dedicated to patient care, research, and biomedical education. Our reputation for excellence in these areas has made us a major center for patient referrals from throughout the Mid-South. Each year, people throughout Tennessee and the Southeast choose Vanderbilt University Medical Center for their health care because of our leadership in medical science and our dedication to treating patients with dignity and compassion.The mission of Vanderbilt University Medical Center is to advance health and wellness through preeminent programs in patient care, education, and research.