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Medical Records Auditor
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Dr Sulaiman AlHabib Medical Centers Job Purpose / Objective
Monitor, review and update patient’s record files both in-patient and out-patient to ensure the completeness and proper documentation are observed with the accordance to both local and international standards. Description
Job Purpose / Objective
Monitor, review and update patient’s record files both in-patient and out-patient to ensure the completeness and proper documentation are observed with the accordance to both local and international standards.
Key Responsibilities / Accountabilities
Review medical records from departments such as Emergency Department (ER), In-patient and Out-patient departments based on review requirements using established international and local standards. Organize and prioritize work to ensure that all review documents are completed in accordance with the pre-set timelines. Work in collaboration with Medical Administration and Quality Department to ensure efficient records reviews are complete. Review prior discharge of patient files for the completeness and by assuring the accuracy of a Medical Records. Follow-up of incomplete documents by calling the concern physicians (consultants, specialists and residents). Coordinate in-service meetings to educate medical staffs on the proper documentation procedures and repot any incorrect or missing documents to the concerned physician and / or HOD for the completion. Actively participates in Quality meetings / reviews as required to certify adherence to established concrete guidelines. Prepare and present monthly report in Quality Meetings and Surveys. Prepare a regular meeting to the physicians known to have deficient medical files for education. Orienting newly hired physicians for all related issues in the department i.e. VIDA System, Approval and Claims. Assure the full representation of clinical pathway in all file compartments. Comply with the standards laid down by the Joint Commission International Accreditation (JCIA) / Central Board for Accreditation of Healthcare Institutions (CBAHI). Follow and apply medical records department policy and procedure and insures that other staffs were following it. Report to Medical Coordinator for any violation of Medical Records Documentation (MRD) and Policies and procedures (P&P). Adhere the safety and security measures and apply the infection control measures. Participate in the hospital education activity program. Participate in, and lead person-centered care initiatives undertaken by HMG. Enrich patient experience with compassion, respect and dignity. Perform all other tasks / duties assigned within the realm of his / her knowledge, skills and abilities.
Requirements
Education / Professional Qualification
Bachelor’s Degree Professional - Nursing; preferably Medicine and Surgery
Experience
Preferably four (4) years’ experience in a medical records environment.
Professional Licensing / Certification / Training
Saudi Council
Seniority level
Seniority level Mid-Senior level Employment type
Employment type Full-time Job function
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