Medical Chart Review Jobs in Indiana (NOW HIRING)

JOB SUMMARY: An exempt position responsible for providing primary care services, including assessing, diagnosing, prescribing, treating, and educating patients. Works closely with physicians and other clinicians in a team approach to patient care. May specialize in a specific type of clinical care, e.g., family practice, pediatrics, geriatrics.

QUALIFICATIONS:

JOB SPECIFIC CORE COMPETENCIES:

• Assesses patients appropriately by obtaining health history and evaluating presenting illness.
• Order/performs diagnostic testing appropriately.
• Documents treatment plan appropriately in the EMR.
• Ability to problem solve using strategic critical thinking skills.
• Must show attention to detail in all aspects of your daily work.
• Must demonstrate effective communications skills within all levels of communication while performing your job.

PREREQUISITE SKILLS:

• Demonstrated communication skills to effectively communicate with management, providers, and patients.
• Operational knowledge of telephones, fax machines, postage machines, and other office equipment.
• Demonstrated ability in handling patient confidentiality.
• Ability to work with peers in a team situation and create a positive work environment for team members.
• Demonstrate a functional and technical understanding of applicable scheduling and billing software, Intranet and Internet usage, Excel/Word software, E-mail Usage and Web-based applications. Required to check e-mail daily and use as a source of internal and external communication. Required to understand and utilize electronic medical record technology.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

The following list describes the essential duties of this role. Individuals in this role may not perform all of these duties, or may perform additional, related duties not listed here.

• Assesses patient status by obtaining health history through patient/family interviews and chart reviews; assessing presenting illness, risk factors, and family history, psychosocial situation, and cultural factors; and performing appropriate physical examination.
• Orders/performs appropriate laboratory diagnostic and other screening tests. Seeks other information as needed, including consultation with physicians and other clinicians, for evaluation of illness. Integrates data to determine diagnosis and therapeutic plan, including identification of any health risks.
• Develops and implements treatment plans by prescribing/dispensing medications and/or injections in compliance with medical practice guidelines and state laws. Handles minor lacerations. Instruct patient/family regarding medications and treatments. Educates patients regarding health promotion/illness prevention. Recommends appropriate community resources to meet patient/family needs. Communicates appropriate case management information to other professionals and community agencies. Prepares documentation for medical records including updating patient medical chart by posting examination and test results, diagnosis, medications, and treatment in written/computerized manner.
• Participate in peer reviews, chart reviews, staff education, clinical guideline development, and other continuing education and quality assurance activities.

Demonstrates the following competencies:

• Demonstrates professional/appropriate dress, verbal and non-verbal communication skills, and effective written communication skills.
• Understands HIPAA guidelines and regulations, acknowledges patient rights.
• Stands as a patient advocate, with appropriate empathy, resolve and respect in communication and actions with patient and family. Recognizes opportunity for improvement regarding patient concerns.
• Demonstrates continual learning, utilizes evidence-based practice to affect change.
• Cultivates effective partnerships and collaborations with providers.
• Understands IT resources.
• Appropriately delegates to ensure optimal operational workflow.

Attitude/Customer Competencies

• Caring, compassionate, and approachable in all customer contacts
• Privacy – respects customers' right to privacy and modesty
• Confidentiality – maintains customers' confidentiality
• Telephone etiquette – speaks so that customers hear a smile
• Appearance – takes personal ownership in appearance and that of work environment
• Initiative – takes necessary steps to fix problems immediately
• Providing Direction and Customer Acknowledgment – provides personalized attention by being courteous, friendly, and helpful when responding to customers' needs
• Timely service – recognizes that customers' time is very valuable; provides them with prompt service
• Customer information/education – provides customers with the best information needed to make informed choices

Relationship Competencies/Work Group Competencies

• Demonstrates advocacy, respect and truth telling
• Demonstrates accountability for own actions
• Demonstrates ability to respectfully address interpersonal conflicts
• Takes initiative to help others
• Demonstrates a learning attitude toward solving problems
• Demonstrates openness to change and new learning
• Reports to work on time and has regular attendance
• Adheres to practice defined dress code
• Attends Staff meetings

Ethical Decision-Making

• Respects the needs, expectations and rights of all individuals
• Advocates the rights of all to a safe environment
• Uses sensitivity to cultural diversity to guide decision-making

Performance Improvement

• Identifies work processes and strives to reduce cost and increase satisfaction
• Identifies customers and demonstrates understanding of customers' expectations
• Actively works to increase satisfaction of all
• Monitors customers' satisfaction
• Takes active role in department process improvement efforts; demonstrates understanding of outcomes
• Demonstrates an understanding of responsibilities
• Demonstrates diagnostic thinking/reasoning
• Utilizes feedback from peers, supervisor, customers to drive performance and behaviors
• Prioritizes workplace safety

CERTIFICATION/LICENSE:

• Current state license as an advanced registered nurse practitioner or physician assistant with prescriptive authority or certification as a PA (general or specialized) from an approved Physician Assistant program and current Indiana state Physician Assistant license with prescriptive authority.
• Current CPR certification.

ADDITIONAL LICENSURE/CREDENTIAL REQUIREMENTS:

• Successful completion of advanced practitioner training and certification as a practitioner (general or specialized) from an approved nurse practitioner program or physician assistant program.
• DEA license

ADDITIONAL EDUCATION AND EXPERIENCE REQUIREMENTS: Mandatory Continuing Education: Customer Service, Fire and Safety, Corporate Compliance (including Confidentiality), Infection Control, and education required by regulatory, accreditation bodies, scope of practice, and/or Hancock Health.

• Minimum two years of nurse practitioner or physician assistant experience.

WORK CONDITIONS

PHYSICAL/MENTAL DEMANDS:

• Assist ambulatory patients independently.
• Sitting up to one hour of day for computer documentation, written reports.
• Walking up to one hour of day.

EQUIPMENT USED: Computer, Telephone, Printer, Fax Machine, Copy Machine, Equipment necessary to treat patients.

ENVIRONMENTAL CONDITIONS:

• Primarily outpatient clinic/office setting.