Employment Type : Full-Time
Overview: Under general supervision of the Director of medical record services/HIM Supervisor , performs various HIM/medical records functions including assembly/analysis, release of information, customer service, and other department duties as deemed necessary by the director and/or supervisor.Responsibilities: Performs filing functions for medical records, including inserting reviewed and signed correspondence into appropriate chart locations.
Creates new medical records for discharged patients.
Provides accurate filing of medical records.
Provides support to Medical Records staff in relation to filing of medical records.
Maintains strict confidentiality of all patient information and documentation.
Assists in other department functions as assigned, such as photocopying, faxing, scanning, uploading files.
Assembly/Analysis/Physician Liaison.
Release of Information: Processes requests for PHI. Follows up with requesting individual. Pulls requested chart and compares requests to chart to be sure there is no breech in confidentiality issue and that all state and federal regulations are met, before releasing information. Answers phone, receives mail and greets department guests and visitors.
Performs release of information functions for patients, patients' family, and visitors: Provides copies (prints) of patient medical record within state and federal guidelines. Completes request within 3 working days.
Performs release of information functions for all requests from outside agencies (Attorneys, Subpoenas, Physicians, Hospitals, Insurance companies, CBO, TARS, etc) Releases patient information in accordance with rules and regulations concerning confidentiality Completes requests within 5 working days. Verifies authorizations, subpoena’s, and court orders (all requests) for validity and completeness and correctness according to state and federal regulations, and hospital policy and procedure.
Uses correspondence application to log in requests. Tracks information pertaining to release of information and copy services; Collects fees for copying; Logs records and mails reports; Files records after copies are made.
Customer Service: Maintains strict confidentiality of all patient information and documentation. PRN-answers within 3 rings; uses proper phone etiquette and customer service skills 100% of the time. Assists in other department functions as assigned, such as photocopying, faxing, sorting and opening mail.
Scanning: A minimum of 20 medical records daily into the electronic medical record.
ETARS: Process for Case Management. Pull, scan or download record. Process audit requests (CMS, Livanta, CDAC,etc)
Transcribed Reports.
H&P/OP/Progress Notes : Daily Run admissions list verify for completed H&Ps within 24 hrs. for all their admissions from the day before and print all the face-sheets for those admissions. Notify physicians for incomplete H&Ps within 24 hrs.
OP reports : Verify that physicians have completed for all the surgeries from prior day. Notify physicians to complete report.
Chart pulls /Chart Retrieval /Outside Storage : Purges charts
SCANNING / UPLOADING DOCUMENTS
Birth Record Registrar: Prepares birth certificates from admission records, information previously obtained from the mother, and information from the Labor and Delivery Unit. Visits mother after delivery to complete and proof?read birth certificates and obtain parent's signatures, exercising courtesy and tact. Inputs information on the infant into the computer and prepares related statistics for permanent records. Submits birth certificate and associated information to town clerk offices and Department of Vital Statistics by established deadlines. Types paternity, disclaimers and birth statements as requested. Handles notarization of affirmation or denial of paternity forms. Files birth information records and enters name of baby on pertinent records. Maintains master birth registry.
Works independently and completes all tasks with minimal guidance from supervisor.
Attends all required Safety Training programs and can describe his/her responsibilities related to general safety, department/service safety, and specific job related hazards.
Follows the Hospital Exposure Control Plans/Blood borne and Airborne Pathogens.
Promotes effective working relations and works effectively as part of a department/unit team inter and intra departmentally to facilitate the department's/unit's ability to meet its goals and objectives.
Demonstrates respect and regard for the dignity of all patients, families, visitors and fellow employees to ensure a professional, responsible and courteous environment.Qualifications: High School Graduate required.
A. or A.S. preferred.
At least 3 years experience in HIM/medical records.
Good written and communication skills.
Good customer service skills.
Hospital Description: Our mission is to provide quality healthcare in a safe environment that is sensitive and supportive to the physical, emotional, spiritual and diverse multi-cultural needs of our patients and their loved ones. We advocate the preservation of human dignity in the delivery of our services and programs.