Roles & Responsibilities
• Audit medical record both open and closed for appropriateness and completeness from the sample size approved by the hospital.
• Prepare audit findings analysis report and provide recommendations on improving documentation.
• Check all patient record item entries in the patient record against the auditing tool.
• Co-ordinate clinical audit activity for all clinical divisions.
• Provide advice and guidance on the completion of all clinical audit projects.
• To ensure clinical audit projects have a SMART action plan in place (where appropriate).
• Maintain an actions tracker identifying outstanding actions and ensuring evidence is provided for all completed actions.
• To ensure non-compliance is escalated to the Clinical Heads, COS, Head Nurses and the Chief of Quality for entry onto the risk register where required and for reporting to relevant committees- QI committee, Medical Staff Executive Committee, or Hospital Executive Committee.
• Contact the concerned person for completion of his/her delinquent entries.
• Participates in and/or leads inter-departmental process improvement initiatives.
• Actively participate in identifying financial issues while conducting clinical audit of medical records.
• Identifies incomplete documentation that could affect a healthcare facility’s livelihood by examining the coding procedures and ensuring the organization complies with regulatory requirements.
• Aggregate the results of the audit and submit a periodic report of the deficiencies to the concern department
• Expected to identify fraudulent claims, outliers, reimbursement deficiencies, inefficiencies, incorrect codes and poor documentation to improvement the organization being challenged by the government or insurance companies.
• Performs patient inquiry audits as requested.
• Provide support to all key quality improvement and patient safety initiatives and work programs.
• Provide education to other healthcare professionals regarding correct documentation and detailed recommendations to improve the organizations procedures and policies.
• Maintain confidentiality during the auditing process.
• Audit patient file presented for review by Mortality and Review committee.
• Leads the Auditing team for the open and closed medical record audit Review.
• Identify variances in the delivery of patient centered care through the Medical informatics auditing process and initiate OVR s for further investigation.
• Participates in the review of all medical records templates hospital wide.
• Performs other duties related to his/her position as needed.
• Provide personalized coordinated care, and support for patients and families.
• Treat people with dignity, compassion and respect.
• Graduate of a recognized, accredited school of Medicine/ Nursing/ Allied Health with current registration in country of origin and a license to work in Saudi Arabia.
• Certified Clinical Documentation Improvement (CDI)
• Minimum of 3 years working experience in healthcare setting specially in auditing medical record.
SPECIALIZED SKILLS :
• Good command of English and Computer skills.
• Excellent communication skills.
• Thorough knowledge, skills and techniques of good patient care.
• Knowledge of Medical record contents and terminology.
• Conflict Resolution.
• Analytical skills
• Facilitation in Problem Solving.
REQUIRED ATTITUDE TO PERFORM THE JOB:
• People management and problem solving skills.
• Positive attitude and ability to work under pressure and time constraints.
• Proper, effective and compassionate communication.
• Flexibility to perform a job.
• Honesty and consistency.