Medical Records Auditor

JOB DESCRIPTION
Designation : Medical Records Auditor
Section/Department : Health Information Management
Reporting to : HIM Supervisor
Responsible for/Reporting Staff :
Purpose and Scope of the Job: Under direct supervision of HIM Supervisor,
Medical Records Auditor is responsible to review and analyze the patient chart
to ensure Physician documentation are complying with hospital policy and
guidelines.
Main Duties and Responsibilities/Performance Standards:
* Daily monitoring of work queues to evaluate electronic medical records are completed in timely manner.
* Perform audit on the completed clinical notes as per the hospital guidelines and ensure all the physicians who have valid consultation / admission are covered in the audit.
* Prepare Physician documentation compliance on timely basis
* Monthly share physician documentation compliance rate to the Clinical HOD and Medical Administration
* Partner with Health Informatics Officer, if any additional training is required for the new joiners (doctors) to complete the documentation in EMR
* Ensure the note types selected to complete the clinical notes are appropriate and followed the standard guidelines.
* Maintain audited cases database for future reference and training as and when required.
* Prepare areas of improvement and slides for clinical departmental meetings
* Maintain patient's confidentiality, security and integrity of the electronic medical record and ensure hospital policies are complied.
* Assist in preparing letters to physician as a reminder to complete deficient documents
* Electronically transcribes discharge summary whenever it is requested by the Customer Service Department.
* Ensures quality and patient safety practices are followed
* Provides or promotes people centered care
* Promotes inclusive health by providing equitable and accessible care to patients and families with special needs.
* Ensures safety standards (occupational and patient safety) are complied.
* Performs miscellaneous job-related duties as assigned by the Direct Reporting Authority.
* Applies knowledge of medical terminology and medical procedures to properly evaluate clinical documents
* Demonstrates responsibility for professional growth and development by actively learning.
* Compiles data into reports for the stakeholders or committee including analysis of trends.
* Ensures quality and patient safety practices are followed
* Provides or promotes people centered care
* Promotes inclusive health by providing equitable and accessible care to patients and families with special needs.

Qualifications, Competencies and Skills:
Education: Degree/ Diploma related with Nursing or Medical Records
Documentation Management
Experience: Minimum ‎1-‎3 previous experience in Medical Records Department
/ Health Information
Licensure: Not Applicable
Language : Proficiency in English Language
Computer Proficiency : Computer literacy - highly skilled in Microsoft
Office
Performance Competencies:
* Ability to work independently and demonstrate problem-solving skills.
* Ability to organize work, set priorities and analyze data accurately.
* Must have good time management skills
* Excellent communication (Verbal and written), organizational skills and attention to detail
* Multi-task oriented with the ability to handle complex issues while providing excellent service to all including physicians, clinical staff, patients, reviewers, etc.
* Accomplishing tasks by accurately checking processes; being watchful over a period of time.

Other Preferences:
* Preferably local with valid and transferable visa in Kuwait

Principle Working Relationships
* Quality Assurance Officer
* Medical Chart Controller
* Statistics Officer
* Medical Coder
* Health Informatics Officer