Medical Record Review Nurse-OR

Revenue Integrity  
Full Time
Day Shift 
4- 10 hr shifts

Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #2 in the state and #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of the Best Places to Work in South Carolina.

The 607-bed teaching hospital anchors a health care network that includes five community medical centers and employs more than 8,000 health care professionals. The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina’s first HeartCARE CenterTM and an accredited Cancer Center of Excellence affiliated with MUSC Hollings Cancer Center for research and education. The network also features an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer’s care center and nearly 80 physician practices.  Its postgraduate medical education programs include family medicine and transitional year.

 

 

 

 

Job Summary

Provides thorough concurrent review of the IntraOp record documentation to capture accurate charges, ensure medical billing compliance, and track implanted tissue. Intra Op record is reviewed to provide a comprehensive and accurate surgical record and assist with departmental, hospital, and regulatory standards. Queries all associated caregivers as necessary via written/verbal communication to validate accurate documentation.

Minimum Qualifications

Minimum Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing (BSN)
Minimum Years of Experience: 3 Years of Clinical Experience in an Acute Care Setting
Substitutable Education & Experience (Optional): None.
Required Certifications/Licensure: Registered Nurse (Current RN license to practice in the state of South Carolina)
Required Training: None.

Essential Functions

• Identifies need to clarify documentation in records. Utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation. Works collaboratively with the healthcare team to facilitate documentation within the medical record.
• Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
• Validate procedure worksheet, implant boxes, graft tracker forms, IntraOp record, Physician's OpNote, and vendor billing sheet (when applicable) to ensure all items match with correct documentation and quantity.

Duties & Responsibilities

• All IntraOp records are checked for accurate acuity to ensure the patient is charged the appropriate OR time and compare to anesthesia time units and PACU time.
• If required, implants are entered into a HIPAA compliant web based application for tracking according to regulatory compliance.
• Performs all other duties as assigned.

We are committed to offering quality, cost-effective benefits choices for our employees and their families:

• Day ONE medical, dental and life insurance benefits 
• Health care and dependent care flexible spending accounts (FSAs)
• Employees are eligible for enrollment into the 403(b) match plan day one.  LHI matches dollar for dollar up to 6%.
• Employer paid life insurance – equal to 1x salary
• Employee may elect supplemental life insurance with low cost premiums up to 3x salary 
• Adoption assistance
• LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
• Tuition reimbursement
• Student loan forgiveness

Equal Opportunity Employer
It is the policy of LMC to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. LMC strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. LMC endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.