Medical Records Clerk

Job Description

Job Description

POSITION SUMMARY:

This position works collaboratively with employees in the Health Information Management Department, the clinical departments, Quality, Utilization, and Risk Management Departments, Medical Staff Office, Patient Access, and members of the Medical Staff to ensure that patient medical records contain accurate and reliable information in accordance with DNV and CMS Standards, hospital guidelines, medical staff bylaws, and state and federal regulations. Depending upon the needs of the HIM department this position could be required to work varying hours on any day of the week. Typical shift will be 8 hours with 30-minute lunch and two 15-minute breaks. Work week typically consists of 40 hours.

Shift: Fulltime Days 

KEY RESPONSIBILITIES:

• Consistently supports and communicates the Mission, Vision and Values of St. Joseph Medical Center.
• Follows the St. Joseph Medical Center Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
• Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation, and prevention of medical errors in a non-punitive environment.
• Supportive of the compliance program set forth by SJMC and demonstrated by:
  • Upholds the Code of Ethics and Corporate Compliance.
  • Adheres to dealing appropriately and fairly with employee misconduct.
  • Enforces all compliance policies as they pertain to his/her area.
  • Provides and assures timely compliance education as requested by the Compliance Officer and/or through corporate initiatives.
• Depending on the needs of the department this position could require collection, prepping, scanning, indexing, or analyzing of a patient's medical record.
• Collecting requirements:
  • Collects all discharged patient medical records from the patient care units daily.
• Completes collecting of all discharge records and reconciliation of discharge report while meeting the productivity standard of 2.5 hours for completion with 95% accuracy.
• Prepping requirements:
  • Prep all records for production into the Electronic Medical Record, including but not limited to lose documents, with 97% accuracy meeting productivity standard of 4 inches of paper per hour. (1 inch = approximately 125 pages)
  • Assembles discharge patient medical records by like document type by date.
  • Prepares the paper medical record for scanning. Includes removing staples, rubber bands or paper clips, looking up and assigning account numbers, unfolding and taping medical recording strips, and straightening wrinkled paper.
  • Completes batch cover sheet for each medical record.
• Scanning requirements:
  • Scans 2500 pages per hour into the Electronic Medical Record (Horizon Patient Folder).
• Indexing requirements:
  • Performs quality check on scanned images. Reviews 97% of images scanned within 24 hours. Identifies at least 98% of documents that are of poor quality.
  • Accurately indexes all images. Indexes documents to correct encounter and document type with 99% accuracy. Performs indexing at the rate of 700 pages per hour.
  • Works Indexing Queues. Reviews assigned work queue(s) daily and ensures timely processing of all assignments in the queues. Writes each indexed batch to the appropriate queue according to workflow procedure.
  • Files indexed accounts.
  • Accounts for all discharge charts. Researches and retrieves any discharged chart not retrieved by prep and scan technicians.
• Other requirements:
  • Good computer and software skills including but not limited to email, MS Word and MS Excel.
  • Reviews assigned work queue(s) daily and ensures timely processing of all assignments in the queues.
  • Records each indexed batch to the appropriate queue according to workflow processes.
  • Monitors supply usage in area and reports supply needs to the HIM Coordinator-Forms Designer for order. Ensures adequate supplies are maintained for area.
  • Analyzes medical records of discharged patients for completeness and accuracy according to departmental policy, hospital Bylaws, Rules and Regulations, and regulatory agencies as requested. (Reference Analysis Productivity Standards for hourly productivity requirements.)
  • Assists Nursing Supervisor with Release of Information on weekends if required.
  • Assist with preparing Fetal Monitor strips.
  • Assist with Retrieval and Filing of Records.
  • Assists with special projects as requested.
  • Records productivity data and total figures at the end of the day. Forwards to Operations Manager as required.
  • Sets an example to all staff in their daily activities.
  • Demonstrates teamwork, accountability, and ownership.
  • Good communications skills; able to work in a team or independently.
  • Demonstrates the ability to be flexible and complete other tasks as needed or requested by the Operations Manager or HIM Director.

REQUIRED KNOWLEDGE & SKILLS:

WORK EXPERIENCE:

• Medical record assembly experience preferred.
• Computer experience required.
• Experience in Meditech.

EDUCATION & TRAINING:

• Ability to read to perform functions outlined in principal duties and responsibilities as typically acquired through completion of high school diploma or equivalent.
• Medical terminology, preferred.

SKILLS:

• Command of the English Language.
• Excellent communication skills both written and oral to explain medical record requirements to others and answer telephones.
• Computer experience including email, MS Office, and MS Excel.
• Ability to perform repetitive tasks with high level of accuracy and attention to details.
• Ability to problem solve independently.
• Ability to work independently and as part of the HIM Team.
• Good analytical skills for performance of indexing functions, analysis, and quality control reviews.
• Terminal digit filing.
• Chart format and workflow.

Houston's oldest hospital is GROWING!

Welcome to St. Joseph Medical Center (SJMC), Houston's first and only downtown hospital delivering world-class care for the last 137 years and looking forward to the next century of exceptional care to Houstonians when they need us most.

Whether it's for a scheduled surgery, the birth of a baby, an unexpected emergency, or an outpatient visit, we have staff available around the clock to provide you access to immediate, quality health care. SJMC has been providing health care services to Greater Houston residents for over 130 years, which should give you great comfort in knowing that we have a great tradition of caring for our community. We strive to meet our patients' expectations and encourage our patients to provide us with feedback on how we can help them have the best experience possible while they're in our care.

Over the last years we have expanded our services to include the Advanced Wound Care Center, Comprehensive Cardiac and Vascular Services, the Women's Center, the St. Joseph Maternal Fetal Medicine Center, and a Weight Loss Surgery Program, just to name a few. As you work with our physicians, nurses, case managers, educators, and other staff, you will be guided through your health care journey, from diagnosis to treatment, with compassion every step of the way.

Diversity, equity, inclusion, and belonging are at the foundation of the care St Joseph Medical Center provides to our community we are privileged to support in all of our employment practices. We do not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or expression or any other non-job-related characteristic.