Medical EMR Specialist

The Medical Electronic Medical Records (EMR) Specialist will work collaboratively with Surgery Center staff and physician surgery coordinators to review booking and presurgical documentation for accuracy and completeness. This role ensures all relevant information, to include but not limited to laterality, site, procedure, and patient details are accurate and properly documented in the patient’s chart before surgery. The Specialist will perform these duties before the scheduled surgery date and coordinate with the physician teams to address and correct found discrepancies prior to patient arrival.

What you'll Do:

• Review surgery booking documents (Booking sheet, surgical orders) submitted via email by physician teams for each patient.


• Review presurgical documents (surgical and anesthesia consents, H&P, last office note) submitted via email by physician team or created by Clerical Specialist for each patient.


• Verify laterality, site, procedure, and patient details match across all documents.


• Ensure all documents are complete and have been entered into the patient’s chart in a timely manner.


• Communicate with the physician teams to address and correct any discrepancies or incomplete information found during the review process.


• Communicate with the Surgery Center staff any discrepancies and assist in the replacement of incorrect documents.


• Maintain thorough records of all reviewed documentation and communications regarding discrepancies for quality tracking purposes.


• Communicate to QA/PI Manager possible trends in discrepancies


• Adhere to all privacy and confidentiality policies and regulations regarding safeguarding patient information.


• Entering incident reports for trending discrepancies.


• Assisting Schedulers or Clerical Specialists with replacing incorrect documents in patient charts.


• Assisting in other Quality Improvement activities as appropriate and assigned.

What you'll Need:

• High School Diploma or Equivalent


• Previous experience in a medical or healthcare setting a plus but not required


• Strong attention to detail


• Strong organizational skills


• Ability to work with with multiple priorities and changing, challenging workload schedules. 


• Proficient with computers and software programs such as Word and Excel. 


• Strong typing skills

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