Medical Records

Essential Duties and Responsibilities: (Specific tasks may be assigned to each assistant by the Team Leader, however duties may be interchangeable)

• Assist in planning, organizing, directing and evaluating the overall operation of the Medical Records/Intake program.
• Assisting in policy, procedure and system development and implementation for the overall operation of Medical Records/Intake program.
• Assist in keeping staff informed of new changes and relevant issues.
• Ensures the accuracy, content and completeness of all client files.
• Assist with the overall operation of the outpatient office by providing relief and coverage.
• Responsible for coding diagnoses and ensuring current diagnoses in the medical record.
• Maintaining and establishing Client II Medical Records files.
• Responsible for ensuring completeness of terminated files prior to keying discharge.
• Responsible for copying records for Social Security Disability, attorneys, and the consumer as requested, per agency policy.
• Responsible for the daily scanning and maintenance of the medical record.
• Responsible for sorting all terminated medical records in preparation for storage when no longer required in the outpatient office (adult charts - seven year, children charts - seven years past their 18th birthday).
• Responsible for maintaining client confidentiality at all times.
• Respond to emergency situations in a timely manner.
• Conduct monthly inspections of the Medication Storage area and Medication Sign In/Sign Out logs for all sample medication. Responsible for sending all outdated medications to the appropriate Regional Site for disposal. Disposing of all medication is documented by completion of log of medications.
• Demonstrate the ability to work effectively with other team members, as part of a multidisciplinary team, and independently, when necessary.
• Answer telephone in a polite, helpful manner and transfer to appropriate staff members as indicated.
• Screen all potential consumers of services utilizing the Admission Outpatient form in Avatar.
• Instruct all new admissions of the necessary documentation to be brought to the first appointment.
• Schedules all appointments per agency policy for all clinicians, nurse practitioners and psychiatrists.
• Greet consumers in a friendly helpful manner.
• Perform general clerical duties to include but not limited to: photocopying, faxing, mailing, and scanning.
• Place reminder calls to all consumers who are scheduled the next day and follow up calls to those that do not keep appointments within twenty four hours of missed appointment.
• Enter all client medications and allergies into Order Connect.
• Process billing documents by ensuring completion of all required fields on service ticket and ensuring that note is entered in the medical record with all required fields.
• Logging all billing documents on patient registers and forwarding all billing documents to the main office as required.
• Process cash payments per agency policy.
• Verify Medicaid/Insurance coverage per agency policy.
• Complete vitals and enter into electronic health record.
• Other duties as assigned.

Requirements

Qualifications: High School Diploma or GED; computer and typing skills; Organizational skills, submitting to and passing successfully a criminal record check and a drug screening test.

Hours: Monday through Friday 8:00 am until 4:30 pm. Evening and weekend hours may be required.

Required Job Skills:

• Oral and written communication skills
• Interpersonal skills
• Ability to exercise good judgment, tact, diplomacy and compassion when problem solving, handling conflict or in a crisis situation
• Ability to complete record keeping in a timely fashion
• Ability to get along with diverse personalities and maintain effective working relationships
• Ability to work well with people of all races, backgrounds and needs
• Ability to work as part of a comprehensive community mental health team and to positively represent the agency in the community

Additional Responsibilities:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made to enable the individual with disabilities to perform the essential functions.

• Physically able to reach, push, pull, stoop, bend, stand, walk and lift up to 20 pounds
• Possess a valid Driver's License and maintain a safe driving record if

required for job performance

• Apply and receive a certificate for being a Notary in the State of Kentucky if required for job

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations must be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee occasionally works in outside weather conditions, may be off-site from normal office location or placed at a Residential Program.

The noise level in the work environment is mild to moderate.

Environmental Data and Job Hazards:

• Hours of work are structured 7.5 hour blocks of time but may be subject to irregular and/or flexible hours based on needs or demands
• Position may require duties to include routine or reasonable anticipated tasks or procedures where there is a degree of actual or potential exposure to blood or other infectious materials.
• All staff are required to participate in yearly trainings regarding infection control and safety in the environment including hazardous waste and blood borne pathogens.
• All new staff must receive training regarding handling physical, verbal threats, acts of violence or other escalating and potential dangerous situations including when police need to be summoned.
• All staff must be certified in Cardiopulmonary Resuscitation within one month of employment and maintain the certification.

Required Job Performance:

• Successful Performance Evaluation on an annual basis. A Performance Improvement Plan will be initiated on all employees who have a negative performance evaluation. An employee will be terminated if the Performance Improvement Plan is viewed as unsuccessful after 2 attempts.