Under general supervision of the director of medical record services , performs various HIM/medical records functions including assembly/analysis, physician liaison, release of information, - transcribed reports (in-house and discharged), scanning, birth records registrar, customer service, and other department duties as deemed necessary by the director and/or supervisor.
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.
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)
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
High School Graduate required.
A.A. or A.S. preferred.
At least 3 years experience in HIM/medical records.
Good written and communication skills.
Good customer service skills.