Summary
Maintains and organizes medical records in accordance with federal and state laws and regulations. Adheres to facility policies and procedures; performs clerical duties associated with the position. Plans, develops and technically evaluates medical records systems to: attain institutional goals, review department performance, and make changes as needed to improve services, and assure compliance with regulatory requirements.
Essential Functions
Compiles, interprets and evaluates statistical or narrative reports relative to medicalrecords services.
Reviews progress notes, doctor's orders, laboratory reports, treatment records, etc., toensure that documents are present.
Processes of incomplete charts. Notifies physicians of delinquent chart status followingthrough with suspension notices, if necessary.
Reviews medical records for internal consistency and completeness.
Assembles medical records in proper sequence and/or verifies that documents are in theprescribed order.
Reviews each document in the chart for the presence of authorized signatures, andminimum patient identification.
Exercises broad knowledge and understanding of medical record procedures so thatrecords which appear to have omissions, inconsistencies, or lack sufficient data arecalled to the attention of physicians and other facility staff.
Responds to requests for information in a professional and courteous manner.
Pulls charts and reports as requested/needed for the Tumor Registry.
Supervises destruction of confidential information within the department, i.e. shredding.
Maintains confidentiality and is ethical in manner when dealing with physicians, staff,patients and visitors.
Serves as a member of the QAPI (Quality Assurance Performance Improvement)Committee. Completes utilization review process: Admission Review, ConcurrentReview, Discharge Review, and Monthly UR Review.
Collects data and statistics to be utilized in the evaluation of the utilization of services.
Conducts monthly and quarterly Quality Assurance Review with the PerformanceImprovement Committee and presents findings.
Ensures availability of medical records for various committee reviews.
Performs other duties as assigned.
Physical Demands
While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.
Required Education and Experience
High School graduate or equivalent (GED).
Experience as a Medical Records Coordinator.
Required Skills and Certifications
Certification as a registered health information technician preferred.
EEO Statement
Our corporation is committed to equal employment opportunity. We do not discriminate against employees or applicants for employment on any legally-recognized basis ("protected class") including, but not limited to: race, color, religion, national origin, sex, pregnancy (including childbirth and related medical conditions), age, disability, citizenship status, status as a current or former uniformed servicemember, genetic information, or any other protected class under federal, state, or local law.
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