As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission. EO/AA

This position assumes responsibility for the management of patient medical records in support of patient care, quality and safety, in complex multimedia systems. The incumbent has demonstrated expertise in the functions of the job and has extensive knowledge of compliance/regulatory standards. This position has no responsibility for providing care to patients.

Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

• Reviews, analyzes and ensures completeness of patient charts in compliance with hospital, state and regulatory standards. Reconciles content of electronic medical record (EMR).
• Manages provider chart completion performance. Prepares weekly documentation deficiency reports and send reports to the appropriate provider.
• Researches declined or miss-assigned deficiencies, including orders and documentation to determine appropriate resolution.
• Validates requests and releases protected health information (PHI) from multiple sources per state, federal, and other regulatory agency guidelines.
• Mastery in retrieving, verifying and releasing all data elements necessary for audits such as RAC, OIG, and PBFS/UMB for compliance purposes according to state, federal and other regulatory agencies.
• Communicates and coordinates with divisions to obtain access and gather necessary documents for release of information.
• Analyzes and abstracts patient charts to complete vital statistics records.
• Interviews obstetrical patients and prepare birth certificates. Electronically transmit birth certificates to the State Health Department. Coordinates with families and appropriate departments to assist with paternity requests and adoption issues.
• Determines appropriate document content and data elements necessary to be retained in the legal physical and electronic medical record and works with the Clinical Documentation Committee on forms content review.
• Acts as liaison between HIM Department, Document Control Library Committee, and hospital staff concerning document submissions and approvals.
• Creates and edits patient forms using standard templates in compliance with Document Management System and LMR Requirements. Prepares documents to be published through document control library approval steps.
• Scans medical records into the EHR and assists in training for institution wide scanning. Performs quality control audits and error correction activities on scanned documents.
• Trains HIM staff, healthcare providers and others in established procedures.
• Collaborates with other staff on a routine basis regarding troubleshooting and problem resolution as needed.
• Audits medical records to ensure compliance with departmental and regulatory requirements, providing feedback on quality measures and proper documentation.

Knowledge / Skills / Abilities

• Demonstrated ability to perform the essential functions outlined above.

• Extensive knowledge of compliance and regulatory standards.

• Knowledge, proficiency and experience in computer based programs and desktop applications.

• Critical thinking, problem-solving and decision making skills.

• Demonstrated excellent verbal/written communication skills.

• Demonstrated human relations and communications skills, and ability to work in a team environment.

• Ability to provide exceptional customer service to patients and customers.

Qualifications

Required

• Demonstrated proficiency in role-specific HIM department functions.
• Three years of experience in a healthcare environment, or equivalency.
• Advanced knowledge of medical terminology, anatomy and physiology, and HIPAA regulations.

Preferred

• Advanced knowledge of EHR, document tracking systems, and/or billing/coding system.

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.