Medical Records Auditor

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.

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