Medical Records Auditor

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General Purpose

The primary purpose of your job position is to audit multiple facility medical records and health information systems with current federal and state guidelines as well as with facility established policies and procedures.

Essential Duties

Every effort has been made to identify the essential functions of this position.

However, it in no way states or implies that these

are the only duties you will be required to perform.

The omission of specific statements of duties does not exclude them from

the position if the work is similar, related, or is an essential function of the position.

Administrative Functions

• Receive and follow work schedule/instructions from your supervisor.

• Coordinate on developing a standardized Medical Records Guide defining which legal documents should be uploaded and maintained in the EHR (PCC)

• Provide input/recommendations on timeline for documents to be uploaded into PCC.

• Develop the baseline for the standard order of a "hard", non-EHR Chart.

• Audit facility patient records for compliance with federal and state guidelines.



*Includes audits to support key PDPM financial drivers.



*Includes audits to support Skilled Nursing Charting and Case Mix Groups



*Includes audits to support UB04 charges.

• Develop templates that facilities can utilize to self-monitor.

• Suggest processes facilities may use to improve compliance with medical records protocols.

• Develop and maintain good working rapport with all facility and therapy compliance teams.

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• Retrieve medical records and deliver as required.

• Become proficient with PCC (EMR).

• Alert facility personnel that key documents are incomplete or missing.

• Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed before chart is closed.

• Maintain spreadsheets on facility nursing audit trends for deficient areas and monitors improvement.

• Issue monthly reports covering audit results to Lead Medical Records Auditor

• Verify and support various Triple Checks monthly.

• Will consult with Regional Medical Records Consultants as appropriate.

• Provide facility assistance with Medical Diagnosis coding.

• Coordinate with EMR Team for additional audits or facility oversight.

• Protect resident health informatio...