Medical Record Specialist - Health Information

Job Title

Monday- Friday

8:30am - 5:00pm

Responsible for scanning and importing clinical documents into the hospital's electronic health record system, performing analysis of closed records for chart completion, assisting with answering the department's main telephone line and releasing medical records upon request, and performing or assisting with other department duties as necessary. This position works with the public so must be customer service oriented.

This position is Full-Time, Monday-Friday, 8:30 a.m. to 5:00 p.m.

Requirements

Knowledge & Experience

Skills-

• Demonstrates verbal and written communication skills.
• Demonstrates ability to use Microsoft Office Word, Excel, and Outlook calendar.
• Demonstrates ability to give and follow instructions accurately.

Knowledge-

• General working knowledge of medical terminology.

Education-

• High school diploma
• Completion of a medical terminology course of study preferred.

Experience-

• A minimum of 1 year of previous health information, clinical, office, legal, or related experience preferred.

Authority and Accountability

• Extensive exposure to confidential information or matters.
• Frequent contact with various persons or groups within and outside of the hospital including employees, department directors, physicians, and outside agency personnel.
• Must be able to work with and communicate with different types of people.
• Must be able to work independently and make appropriate decisions regarding basic release of information processes.
• Must be able to complete assigned duties with a minimum of supervision.

Aptitudes

• Must be able to prioritize, utilize critical thinking, and adjust to change in work assignments and other change.
• Must be able to reason and use logical problem-solving skills.
• Performs some duties that require some latitude for independent judgement and initiative in handling situations out of the ordinary.

PHYSICAL AND MENTAL EFFORT

• Regular requirement to walk, stand, use hands, reach with hands or arms, talk and hear, sit.
• Frequent requirement to lift up to 25 pounds.
• Specific vision requirements include close vision, distance vision, and the ability to focus.
• Speaking and listening skills are essential.
• Must be detail oriented.
• Time management and multiple task management skills are essential.
• Must be able to work under a moderate amount of stress.
• Must be able to read, write and do simple calculations.
• Must be able to follow written and oral instructions.

ENVIRONMENTAL AND WORKING CONDITIONS

• The noise level in this work environment is usually moderate.
• Work is performed in a clean, well-lighted and ventilated building.
• Could be subject to infectious diseases, cuts, abrasions, burns, and punctures.
• Work schedule may vary in accordance with the responsibilities associated with the position.

ACCOUNTABILITY

• Reports to the Director of Health Information.

QUALITY ASSURANCE-KEY RESPONSIBILITIES

1. Performs documentation analysis of closed records to assure compliance with established guidelines set by Medical Staff Rules, Regulations and Bylaws, hospital, state, and federal guidelines.
2. Scans and imports clinical documents into the hospital's electronic health record system in a timely and accurate manner.
3. Makes corrections in the Master Patient Index as necessary.
4. Performs document pickup, drop-off, sorting, and second-checking duties as assigned or as necessary.
5. Distributes documents for clinician signature (paper and/or electronic versions) as necessary.
6. Assists with other department duties as necessary or as assigned.
7. Enters notification in patient electronic health records upon notice of patient expiration as assigned.
8. Assist with answering the department's main telephone line as necessary and as assigned.
9. Assist with the performance of release of information functions as necessary and as assigned.
10. Performs other duties as assigned.

PUBLIC RELATIONS

• Maintains effective channels of communication with other employees.
• Takes appropriate action in problem situations to minimize potential adverse effects.
• Projects a professional and positive attitude regarding the hospital and the department.

OTHER RESPONSIBILITIES

• Observes hospital dress guidelines and wears hospital issued identification badge.
• Provides proper notification for absences and is punctual for start of scheduled work time.
• Participates in emergency procedures, fire drills, evacuation procedures, and other internal/external disaster response.
• Demonstrates support for and contributes to the hospital's mission, vision and values.

CONTINUOUS QUALITY IMPROVEMENT

• Participates in the hospital's Quality Improvement Program by:
• Bringing potential problems to the appropriate person's attention.
• Assisting in data collection.
• Suggesting solutions to the problems.
• Emphasizing, supporting, and committing to quality improvement practices and processes.

Rush Memorial Hospital