KEY RESPONSIBILITIES:

　　· Run daily AIS reports to validate and account for patient discharges, both Inpatient and Outpatient.

　　· Pull charts for review and analysis on a timely basis as required by policy and by regulation.

　　· Assemble and analyze discharged patient charts and review Inpatient and Outpatient records according to department standards.

　　· Responsible for managing patient health records.

　　· Identify chart deficiencies for missing details (i.e., Protected Health Information, signatures, dates, times, and details) and charting.

　　· Document deficiency findings using the deficiency tools in software and on corresponding audit forms.

　　· Enter deficiencies into AIS.

　　· When charts have been completed by the physician or midlevel, reanalyze the pt charts for accuracy and remove deficiencies from AIS accordingly.

　　· Create and maintain patient charts based on established department guidelines.

　　· Ensures medical records are assembled in standard order and are accurate and complete.

　　· Assist in retrieving charts for stakeholders for chart completion.

　　· Retrieve and re-file the patient’s medical records, as needed.

　　· File loose filing daily into the proper charts. Prepare charts for patient discharge process.

　　· Creates or scans digital images of photos, forms or records to be included in the electronic medical record.

　　· Responds to requests for patient records, both within the facility and by external sources, retrieving them and transmitting them accurately, timely, and appropriately.

　　· Process all requests for medical records received by mail, fax, or phone according to State and Federal requirements.

　　· Ensure that the release of information is completed properly, timely, and valid.

　　· Collaborate with other departments to gather records needed to ensure timely and compliant billing.

　　· Assist in answering telephone and taking accurate messages.

　　· Pulling charts for physicians, nursing and other hospital personnel.

　　· Perform audits as requested.

　　· Assist in processing dictated and/or transcribed reports.

　　· Print reports as needed for timely inclusion into the patient’s active medical record.

　　· Work with the physicians, midlevels, and other hospital personnel to answer questions regarding dictation or transcription.

　　· Ensures that errors by outsourced transcription company are corrected and sent to the document’s author for review and signature.

　　Requirements

　　Knowledge and Experience:

　　· High school diploma or equivalent.

　　· One year of experience working with medical records preferred.

　　· Coursework specific to regulations pertaining to proper administration of medical records preferred.

　　· Demonstrated knowledge of patient privacy and security, HIPAA, CMIA, and LPS relative to maintaining medical records required.

　　· Knowledge of medical terminology preferred.

　　Skills and Abilities:

　　· Promote patient, physician, customer and employee satisfaction by personal example, treating all contacts with respect

　　· Support and participate in activities that foster customer service

　　· Communicate and follow the organizational chain of command for notification of patient care/service issues, when appropriate

　　· Maintain a complete knowledge base of record completion requirements

　　· Maintain consistent productivity and quality of work in a challenging, fast paced and rapidly changing environment

　　· Closely adhere to set schedules and timecard procedures

　　· Identify, resolve and escalate major issues and service failures that impede success

　　· Maintain confidentiality of all patient demographic, medical, and financial information, ensuring proper handling and disposal of confidential documents and adherence to HIPAA

　　· Comply with all applicable Federal, State, and local laws, regulations, and requirements as well as PH&S policies and procedures in all aspects of job performance

　　· Attend and successfully completes general and department orientation, in-service programs and the annual key competencies and mandatory update requirements

　　· Participate actively in department staff meetings

　　· Demonstrate effective verbal and written communications

　　· Communicate effectively in all interactions in a clear, concise, understandable manner.

　　· Actively seeks constructive feedback and remains open and receptive to it

　　· Anticipate the information needs of others

　　· Demonstrate competency by maintaining positive, constructive interpersonal relationships, and by understanding and practicing the principles of effective teamwork

　　· Take responsibility to support team members in meeting project milestones and objectives.

　　· Perform challenging tasks efficiently and effectively

　　· Show strong, meticulous attention to detail and excellent analytical skills

　　· Demonstrate performance by adhering to established policies and procedure and exhibiting the defined characteristics associated with attendance and punctuality

　　· Monitor work queues and perform problem resolution/corrective action where needed

　　· Analyze medical records for completeness and compliance

　　· Assign documentation deficiencies to the correct physician, nursing, or other hospital personnel

　　· Process, scan and index medical records for accuracy, completeness and compliance into the correct paper or electronic medical record

　　· Confirm authorizations for release of information for requests as necessary

　　· Respond to business office requests for information and copies of specified documents

　　Physical Requirements:

　　While performing the duties of this job, this position is frequently required to do the following:

　　· Use standard office equipment and access, input, and retrieve information from a computer. Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.

　　· Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.

　　· Frequent bending, squatting, kneeling, climbing with the use of a step stool and twisting. Lift and carry up to 20 pounds.

　　· Sit or stand for minimum periods of one hour at a time. Come and go from the work area repeatedly throughout the day.

　　· Give and follow verbal and written instructions with attention to detail and accuracy.

　　· Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.

　　· Vision: see details of objects at close range.

　　· Coordinate multiple tasks simultaneously.

　　Benefits

　　Medical

　　Vision

　　Dental

　　401(k)

　　3.5 Weeks Paid Time Off

　　$25,000 Life insurance policy is provided at no charge to the employee