Medical Record Operations
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.
• 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.
• Critical Thinking (Novice): The objective analysis and evaluation of an issue in order to form a judgment.
• Compliance (Novice): Understanding the rules, regulations, sanctions and other statutory requirements, guidelines and instructions relating to governing bodies and organizations, both internally and externally.
• 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.
• 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.
Our professional administrative functions include critical supporting roles in information technology and informatics, finance, administration, legal and community affairs, human resources, communications and marketing, development, facilities, and many more.
At our growing health system, we support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at Vanderbilt Health for professional growth, appreciation of benefits, and a sense of community and purpose.
- 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.
Core Capabilities :
Supporting Colleagues: - Develops Self and Others: Continuously improves own skills by identifying development opportunities.- Builds and Maintains Relationships: Seeks to understand colleagues' priorities, working styles and develops relationships across areas. - Communicates Effectively: Openly shares information with others and communicates in a clear and courteous manner. Delivering Excellent Services: - Serves Others with Compassion: Invests time to understand the problems, needs of others and how to provide excellent service. - Solves Complex Problems: Seeks to understand issues, solves routine problems, and raises proper concerns in a timely manner. - Offers Meaningful Advice and Support: Listens carefully to understand the issues and provides accurate information and support. Ensuring High Quality: - Performs Excellent Work: Checks work quality before delivery and asks relevant questions to meet quality standards.- Ensures Continuous Improvement: Shows eagerness to learn new knowledge, technologies, tools or systems and displays willingness to go above and beyond.- Fulfills Safety and Regulatory Requirements: Demonstrates basic knowledge of conditions that affect safety and reports unsafe conditions to the appropriate person or department. Managing Resources Effectively: - Demonstrates Accountability: Takes responsibility for completing assigned activities and thinks beyond standard approaches to provide high-quality work/service. - Stewards Organizational Resources: Displays understanding of how personal actions will impact departmental resources. - Makes Data Driven Decisions: Uses accurate information and good decision making to consistently achieve results on time and without error. Fostering Innovation: - Generates New Ideas: Willingly proposes/accepts ideas or initiatives that will impact day-to-day operations by offering suggestions to enhance them. - Applies Technology: Absorbs new technology quickly; understands when to utilize the appropriate tools and procedures to ensure proper course of action. - Adapts to Change: Embraces changes by keeping an open mind to changing plans and incorporates change instructions into own area of work.
Relevant Work Experience
High School Diploma or GED
For a copy of the physical requirements of this position to determine if you can perform the duties with or without an accommodation or to request an accommodation, please contact VUMC Employee Relations at 615-343-4759 or email@example.com .