POSITION SUMMARY

Responsible for reviewing the medical records documentation aspect in completion of medical records, mainly the Physician’s medical records documentation based on Joint Commission International Accreditation Hospital Standards and Ministry of Health / Sharjah Health Authority regulations.

POSITION REQUIREMENTS/QUALIFICATIONS

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• Bachelor’s degree in general medicine, nursing, dentistry or related healthcare field.

• A Qualification in healthcare field and experience in EMR Auditing in an accredited hospital and participation in JCI survey.
• Must be well versed with the Computer Skills (Word and Excel).
• Excellent command of oral and written English.
• Certification as a Clinical Auditor (preferred).
• Strong knowledge of ICD-10 (preferred).
• CPHQ (preferred).

POSITION CRITERIA OTHER SKILLS/ABILITIES

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• Excellent analytical and critical thinking skills.

• Strong communication and interpersonal skills.
• Proficient in using electronic health record (EHR) systems and auditing tools.

SUMMARY OF MAIN DUTIES

• Conduct Comprehensive Audits:
• Perform detailed reviews of medical records to evaluate the quality and accuracy of clinical documentation.
• Validate the audited medical records by the physicians assigned auditing team.
• Use established criteria and auditing tools to assess compliance with organizational policies, state and federal regulations, and accreditation standards.
• Ensure Documentation Accuracy:
• Verify that all medical coding (ICD-10, CPT, HCPCS) corresponds accurately to clinical documentation and aligns with diagnoses and treatments provided.
• Identify discrepancies or errors in documentation and coding that could impact patient care or reimbursement.
• Provide Feedback and Education:
• Collaborate with healthcare providers and clinical staff to communicate audit findings and offer constructive feedback.
• Conduct training sessions to educate staff on best practices in clinical documentation and coding, aiming to improve overall quality.
• Regularly review and act on the findings of non-compliance (if any) and communicate to concerned.

RESPONSIBILITIES

• Stay Current with Regulations:
• Maintain up-to-date knowledge of legal and regulatory requirements affecting medical recordkeeping and coding.
• Monitor changes in guidelines and standards, ensuring that audit practices and processes are aligned accordingly.
• Participate in Quality Improvement Initiatives:
• Engage in organizational quality improvement programs aimed at enhancing patient care and clinical operations.
• Work collaboratively with interdisciplinary teams to implement changes based on audit findings and recommendations.
• Assure Compliance with HIPAA:
• Ensure that all auditing activities are conducted in compliance with HIPAA regulations, safeguarding the confidentiality and security of patient information.
• Educate staff on the importance of patient privacy and data protection as it relates to documentation practices.
• Maintain Documentation of Audits:
• Keep accurate records of all audits performed, including methodologies, findings, follow-up actions, and resolutions.
• Use auditing software or systems to track audit activities and findings systematically.
• Support Management and Leadership:
• Provide insights and recommendations to management regarding trends in clinical documentation and coding practices.
• Assist in the development of policies and procedures related to medical recordkeeping and audits.