The Health Information Management Discharge Analyst/Auditor reports to the Manager of Health Information Management. The Discharge Analyst Auditor will be the primarily responsible for EMR audits on content of documentation based on the requirements of regulatory guidelines as well as NHRMC policies. Responsibilities include DNV reporting, DNV ISO Auditing requirements for reporting and Quality Improvement. Analysis of Medical Records for deficiencies and completion.
1.Completes audits on medical record documentation for content based comparing to the documentation regulatory requirements and NHRMC policies and Medical Record Rules and Regulations.
2.Maintains database/spreadsheets of the audit results. Reports to Manager/Director the results of the audits as required. (Graphs, Spreadsheets)
3.Identifies, researches and analyzes documentation. Completes detailed analysis of the data/findings, identifies non-compliant items and makes recommendations for process for performance improvement. Researches regulations to support audits or audit findings.
4.Quality Assurance. Continuous audit findings follow up and re-audit to demonstrate improvement or need for further PDSA (Plan Do Study Act). Utilizing DNV ISO requirements.
5.Ownership of the process and ability to convey/communicate findings/educate and drive the results for improvement, by interacting and effectively collaborating with Physicians, Providers and Clinicians to include Management level personnel.
6.Analyze medical records for completeness, ensuring that all regulatory requirements are met. Assigning deficiencies to the providers as needed, and removing deficiencies when completed.
7.Identifies opportunity and acts as a teammate to the Epic IT team as needed for process improvement/functionality in the EMR. Key contributor with the implementation of new or revised documentation workflows in Epic.Assist providers as required for documentation templates creation, revision as needed to meet the requirements of the required elements of regulatory content of medical record documentation.
8.Utilizes all applications for data retrieval, tracking, analyzing.
9.Assist in the process/communication to the provider VROP (Voluntary Relinquishment of Privileges) as requested.