Documentation Management Specialist - Coord Clinical - Bon Secours Healthsource

Documentation Management Specialist - Coord Clinical - Bon Secours Healthsource - Richmond

Provides data abstraction and/or scanning of external documents in accordance with Enterprise CC and BSMG policy to ensure ease of retrieval of such information by providers and staff across BSHSI.

Essential Job Functions:

• Retrieves records from patient care areas as needed to facilitate an efficient and effective workflow.
• Performs chart abstraction by extraction and data entry of key data elements from a variety of clinical sources (paper or other medium) into the Epic electronic health record.
• Enters Health Maintenance information into discrete fields to ensure MU/MSSP data is available and to enable reporting on key measures.
• Works with providers to ensure data is transferred from the paper and/or electronic source to their satisfaction.
• Proofs completed abstracts daily to ensure the integrity of the data entered.
• Preps and scans documents from external sources.
• Scans documents into the electronic health record utilizing the Enterprise CC and BSMG protocols.
• Indexes documents with proper Level, Document type and Description to ensure ease of retrieval by providers/staff across BSHSI.
• Maintains a productivity level as specified in predefined performance standards and established accuracy rate.
• Interacts and contacts other clinical resources as needed to clarify medical record documentation as needed.
• Monitor and problem solves as necessary on issues such as invalid patient information to ensure a complete and accurate abstract.

Required Qualifications:

• Experience within a physician practice setting.
• Prior experience with an electronic archival system highly desired.
• Working knowledge of medical record format and content of patient records.
• Ability to review records, read physician documentation and verify patient identification.
• Good interpersonal skills and ability to communicate with practice managers and other medical group staff/leadership.
• Work requires a high level of accuracy with the ability to concentrate on detailed information for extended periods of time.

Preferred Qualifications:

• Licensure as an LPN or MA preferred

Other Functions:

• Works closely with the Clinical Support Services team.
• Other duties as assigned

Working Conditions:

• The individual performing this job may anticipate possible contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies regarding infection control.
• Travel outside the office is required.
• Overnight travel on occasion to attend seminars and training.
• Periods of high stress and fluctuating workloads may occur
• May be exposed to high noise levels and bright lights
• May have periods of constant interruptions

Skills:

• Able to follow general instructions
• Possess surgical conscience
• Moves with a sense of urgency
• Understands basic anatomy/physiology
• Knowledgeable in infection control practices
• Knowledgeable of AORN and AST recommendations related to practice
• Anticipates needs of surgeon, team, and patient
• Self-directed
• Able to work independently
• Critical thinking
• Remain calm under pressure
• Strong communication skills
• Able to handle self in a professional manner
• Takes direction
• Basic Windows application computer skills

Working Conditions:

• Periods of high stress and fluctuating workloads may occur
• May be exposed to physical altercations and verbal abuse
• May be exposed to adverse weather conditions; cold, hot, dust, wind, etc.
• May be exposed to limited hazardous substances or body fluids*
• May be exposed to human blood and other potentially infectious materials*
• May have periods of constant interruptions
• General office environment
• Required to car travel to off-site locations, occasionally in adverse weather conditions

* Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices and learn the policies concerning infection control.

Scheduled Weekly Hours:

• 40

Work Shift:

• Days/Afternoons

Department:

• Bon Secours Healthsource - Richmond

Bon Secours Mission, Values, Customer Orientation and Continuous Quality Improvements Focus:

It is the responsibility of all employees to learn and utilize continuous quality improvement principles in their daily work.

All employees are responsible for extending the mission and values of the Sisters of Bon Secours by understanding each customer, treating each patient, staff member and community in a dignified manner with respect, kindness, and understanding and subscribing to the organization's commitment to quality and service.

The above statements are intended to describe the nature and level of work being performed by individuals assigned to this classification and are not to be construed as an exhaustive list of all job duties. This document does not create an employment contract, and employment with Bon Secours Health System is "at will".

Bon Secours is an equal opportunity employer.

Many of our opportunities reward* your hard work with:

• Comprehensive, affordable medical, dental and vision plans
• Prescription drug coverage
• Flexible spending accounts
• Life insurance w/AD&D
• Employer contributions to retirement savings plan when eligible
• Paid time off
• Educational Assistance
• And much more

*Benefits offerings vary according to employment status

Bon Secours is an equal opportunity employer.