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 home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period. Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As t...he largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.