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About the Role
The Outpatient Records Specialist will conduct audits of patient case records to identify documentation errors, ensuring the quality and completeness of clinical documentation. This role facilitates modifications to documentation through interaction with physicians and staff, ensuring compliance with regulatory and agency procedures for billing and payment. The specialist will also extract, compile, and report data from the electronic health records system and provide ongoing monitoring to ensure adherence to established procedures and accreditation requirements. Training in records management may also be provided.
Responsibilities
- Conduct full audits of patient health records in collaboration with the Outpatient Clinical Services Director and outpatient management team.
- Ensure all services provided are billable by maintaining documentation compliance with OASAS, OMH, OMIG, DOH, CARF, and other governing agencies.
- Act as a liaison to inform staff of documentation errors found during reviews and trainings.
- Review medical records and pertinent documentation concurrently and retrospectively.
- Extract, compile, analyze, and report on data from the electronic health records system.
- Prepare periodic reports on quota, waiting lists, case type, acuity level, demographic information, and other specified criteria.
- Utilize MS Excel spreadsheets to track documentation workflow and provide status reports.
- Address EHR help desk tickets as trained and directed.
- Communicate with the billing department regarding the readiness of services for billing.
- Uphold the standards of the agency’s Continuous Quality Assurance Program.
- Participate in Continuous Quality Improvement Committee meetings, as assigned.
- Maintain documentation, correspondence, and communication with other providers regarding psychiatric, medical, and substance abuse services.
- Promote individual professional growth and development by meeting continuing education and skills competency requirements.
- Provide training to clinicians and administrative staff.
- Perform other duties as requested, directed, or assigned.
Requirements
- Must be able to perform each essential duty satisfactorily.
- Must maintain valid driver’s license and acceptable driving record.
Skills
- Data extraction
- Data compilation
- Data analysis
- Reporting
- MS Excel
- Electronic health records system
- Records management
- Auditing
- Quality assurance
- Communication
Location
- Remote options available after successful probationary period
Work Type
- Full-Time
- Remote
Experience Level
- Not specified
Education Level
- High School Diploma or GED required
- Two-year degree preferred in statistics, math, business administration, or computer science