Document Control Specialist

Document Control Specialist

The Document Control Specialist is responsible for prepping, scanning and indexing the clinical paper documentation (medical records) for Jefferson Health Center City. This includes but is not limited to records for hospital and physician practice documentation. The Document Control Specialist performs quality review of the documentation ensuring that clear patient identifiers, service dates, authentication and other regulatory requirements are included on each document in accordance with The Joint Commission, State and Federal Laws and other regulatory entities. This resource is responsible for assigning documentation to the correct patient, encounter and document type in the EHR. Provides timely, accurate and accessible electronic patient health information. Works with the Manager of HIM Document Management & Record Integrity to ensure all clinical documentation is accessible within the EHR within 24 hours of creation or defined time frame.

Essential Functions:

• Performs duties that include the preparation, scanning, indexing, and quality analysis of paper documentation for both Hospital and Jefferson University Practices (JUP) paper medical records.
• Ensures documents are aligned, maintained and uniform in the EHR (Epic and Onbase)
• Pick-up and deliver documents from medical practice and/or hospital units to HIM central location. Responsible for tracking and verifying receipt of discharged patient records.
• Preps all pages for the scan process (i.e removing staples and making sure the quality of the document is readable)
• Responsible for verifying appropriate patient identification is on every page of the document (both sides).
• Scans medical record documentation following established process, in a timely manner, to ensure information is available for patient care. Inspects the quality of each document scanned.
• Manually indexes documents to the correct patient, encounter, document type and document date. Indexes documents associated with orders to the correct order number so that the order closes in the EHR.
• Assesses documents received from RightFax determining if they need to be routed to Clinical Support personnel in accordance to established guidelines. Indexes documents to the correct patient, encounter, document type and document date.
• Performs qualitative analysis of scanned and indexed documentation to ensure the integrity of the electronic health record. Validation of the paper record to scanned images to ensure a complete and legible record.
• Assist with corrections of documents scanned and indexed by other departments. This includes but is not limited to re-indexing of document types, removing duplicate documents, moving documents to the correct encounter or patient record.
• Inspects the equipment used for scanning and indexing on a daily basis. Responsible to keep equipment clean to ensure clear capture of the scanned document. Reports inventory of supplies to management as needed.

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

Other Functions and Competencies:

• Ability to work with computerized systems.
• Works with department staff and healthcare providers to ensure clinical documentation is collected, scanned and indexed in the EHR.
• Maintains compliance with government and legal requirements relative to medical records by validating two patient identifiers are included on each patient record.
• Ability to adapt to changing environment in a professional manner.
• Must be able to push a WOW (Workstation on wheels), stand and walk around for long periods of time.
• Able to process digital images and index to the correct patient medical record, while assuring strict confidentiality and compliance to HIPAA regulations.

Educational/Training Requirements:

High School graduate or equivalent with GED. Experience in Health Information Management preferred. Prior experience in scanning and/or indexing of documents in an EHR. Good communication skills.

Experience Requirements:

Knowledge of medical record imaging format and content.

Ability to review records and verify patient identifiers are included.

Ability to perform job function and make decisions with limited supervision.

Ability to interact with healthcare providers.

Good organizational skills with ability to prioritize tasks.

Good communication skills required.

Ability to walk around campus and push WOW (Workstation on wheels) weight over 50 lbs.

Additional Information:

Maintains work schedule assigned. Schedule to possibly include weekends and holidays to ensure coverage is maintained for a 7 day a week scanning operation.

Work Shift: Workday Day (United States of America)

Worker Sub Type: Regular

Employee Entity: Thomas Jefferson University

Primary Location Address: 111 S 11th Street, Philadelphia, Pennsylvania, United States of America