Medical Record Specialis

Responsibilities:

Compiles statistical data, such as admissions, discharges, deaths, births, and types of treatment given.
Abstracts information for the medical record.
Analyzes records in accordance with the HIM analysis procedure with a minimum of 95% accuracy.
Performs quantity and quality checks on scanned medical record information as part of Quality Control (QC) function.
Accurately completes daily, weekly, monthly, and quarterly reports
Ensure all scanned documents are scanned in chronological order
Ensure patient identifiers are present on all scanned pages
Ensure that all scanned documents belong to the same patient with the same date of service
Verify that images are correct and legible. Review each electronic image and compare with the hard copy to confirm the image quality, appropriate order and appropriate rotation.
Conducts quality assurance and quality improvement on scanned/indexed documents
Enters, edits and tracks medical record deficiencies in chart management system. Effectively communicates with physicians to resolve and manage physician deficiencies.
Reviews medical records edited by physicians and updates the HIM system as needed.
Compiles, updates, and reports physician record completion statistics and physician notification letters. Prepares physician list and handles the suspension process.
Produces and distributes delinquency notification/suspension letters, verifies accuracy of deficiency information, reports physician record completion statistics and updates.
Monitors records submitted for reanalysis to ensure accurate completion of records. Ensures completion of existing file deficiencies and verifies accuracy of information submitted
Serves as a liaison to physicians regarding issues related to incomplete records and documentation to ensure adherence to Joint Commission standards and compliance requirements.
Facilitates chart availability and readiness for coding.
Assures patient’s records have been received upon patient discharge.
Facilitate the completion of birth certificates and ensure they are filed with the correct registrar within the state requirements.
Assists patients with patient portal questions and password re-sets.
Assists visitors and physicians, and answers phone as needed.
Monitors the transcription system if needed.
Coordinates the ROI function if needed.
Responsible for the integrity and quality of the documents that are scanned into the document management system, tracking of unidentified documents, re-scanning documents, assigning document types to unknown documents.
Ensures that all discharged records are received from the units for document imaging. Performs follow up of missing documents and verification that all charts have been received and scanned.
Continuously meets all turnaround times as requested and per Departmental policy.
Responsible for analysis of patient’s records for needed documentation by the physician as well as for the physician suspension process and record deficiency tracking.
Operates computer to enter and retrieve data.
Accepts subpoenas after verifying their validity.
Responsible for accurately scanning authorizations, subpoenas, request into the system.
Ensures all documentation is accurate and in the appropriate format to meet Joint Commission accreditation standards.
Reviews the integrity of the Master Patient Index (MPI) to provide an accurate database, ensure each patient and number is uniquely and correctly identified.
Combines patient records that are duplicated; pull and combine chart to merge the physical record.
Handles all incoming calls regarding registration issues due to duplicate or incorrect number assignment.
Maintains log of activities. Continuously meets all turnaround times as requested.
Meets or exceeds productivity standards.
Responsible for cross-training peers.
Assists the HIM Department and various work units during times of staff shortage or high volumes –
Responsible for other duties and special projects as assigned by management.
Maintains strict physician and patient confidentiality
Follows all federal, state, industry, and hospital guidelines for release of information.
Supports Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by in-service attendance and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient information.
Reviews materials, complete all required client policy training documents and passes required tests.
SKILLS:

Demonstrates a positive attitude and the ability to communicate effectively with customers, staff, management and peers.
Fosters respect for patient privacy by maintaining confidentiality in all phases of work. Prioritizes daily work responsibilities and manages time well in order to consistently meet deadlines.
Demonstrates the ability to work under pressure and comply with high productivity standards and expectations.
Adapts to change easily and is able to work in an environment of continuous change. Demonstrates initiative and willingness to assist the department as needed.
Ability to work effectively in a team environment.
Performs other related duties as assigned or requested
QUALIFICATIONS:

High school graduate or GED required.
Minimum one year of previous HIM or equivalent experience or education required. Proficiency with HIM computer systems required. Previous office clerical or administrative experience preferred. Knowledge of medical terminology.
Strong computer knowledge including MS Office (Outlook, Word, Excel). RHIT/RHIA Certification is a plus.
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