Medical Records Clerk

Job Title

To be fully engaged in providing Uncompromised Safety, Superior Quality, Memorable Patient/ Customer Experiences, and Financial Stewardship by:

1. Maintaining accurate and complete medical records for each patient treated at Health First.
2. Assuring that the confidentiality, security, and integrity of the data and information is maintained.
3. Abstracting and compiling clinical data in a meaningful manner to allow for quality improvement, benchmarking, identification of trends and development of action plans.
4. Our goal is to provide complete and timely use of data and information, without compromising security and confidentiality. Responsibilities may vary based on job role within the department.

Primary Accountabilities:

Quality/No Harm:

• Demonstrates competence in the following clinical applications to include: SCM, ED Manager, eMon, SIS, HPF/QCI, RRA, Laserfiche and Midas. Proficiently navigates through the above listed clinical applications in order to:
• Identify patient using two patient identifiers and able to locate appropriate chart based on that information.
• Verify the accuracy of demographic area.
• Proficiently navigates through Microsoft Office applications to include: Word, Excel, and Power Point.
• Responsible for confidentiality, security, and integrity of all personal health information for all patients
• Writes scanned and indexed batches to the appropriate queue according to departmental policy and procedure at least 98% of the time.
• Monthly, ongoing chart reviews (Clinical Pertinence, Medical, Surgical and Critical Test Results) are completed in a timely manner 100% of the time. Results are tabulated and formatted in a consistent manner for presentation on a timely basis. Reports are available for review one week prior to the date of presentation. These reviews include medical record review committee audits as well as audits related to Patient Safety, Quality Improvement, National Patient Safety Goals, etc.
• Items which fall out on audits are copied and forwarded to a designated person responsible for follow up with the appropriate parties at each facility.
• Maintain and coordinate review forms for chart reviews across all facilities and chairs/co-chairs Medical Record Review Committee.
• Assist in validation and monitoring of quality related to content and completeness of legal health record.
• Adequately prepares for meeting(s), sending or emailing notices and preparing the agenda. Attends meeting on time to distribute packets to members. Completes original minutes for committee binder.
• Responsible for attending and reporting results at assigned facilities and assisting in creating action plans to improve compliance and documentation.
• Participation in Joint Commission Readiness meetings, chart reviews and assist as necessary to surveys.
• Complete additional focused reviews as assigned by HIM Manager.
• Responsible for correcting incorrect chart documentation to include wrong patient, wrong accounts, and other discrepancies.Performs Adjust Document Index function to include correctly inserting, splitting, moving, and appending pages/documents when and where appropriate at least 98% of the time.
• Charts are accurately analyzed according to Joint Commission requirements and Medical Staff Bylaws and Rules and Regulations, correctly identifying missing elements and assigning deficiencies to the correct physician at least 98% of the time.

Customer Experience:

• Provide patient information to appropriate requesters in a timely and efficient manner.
• Understands the confidentiality of patient information and proper dissemination of this information. Adheres to all Health First policies and procedures in regards to protected health information. Consults with management to clarify any concerns.
• Coordinates on-site medical record audit requests for external and internal requestors.Audits are available for review to authorized individuals at the time and date agreed upon when the request was submitted.
• Provides assistance with any questions the physicians may have about their deficiencies and how to access assignments/complete deficiencies through the physician portal or directs the physician to the appropriate person for clarification.
• Works closely with the Quality Department regarding documentation compliance and record content.

Stewardship:

• Takes initiative to take on additional assignments or changes in scheduling based on daily observations in a willing manner.
• Assesses the need to contribute to analysis or other areas that could be falling behind departmental targets.
• Ensure that all external audits are appropriately followed up and completed after approval of the HIM Manager 100% of the time Understands and supports the processing of reports according to department turn-around-time goals.

Work Experience

Qualifications Required:

• RHIA or RHIT or eligible within 24 months
• 1-3 years of previous health information management experience preferred
• Excellent computer skills and proficiency with Microsoft Office applications
• Understanding of Joint Commission standards, State Regulations, HIPAA, CMS and Medical staff rules and regulations requirements preferred

Physical Demands:

• Visual acuity to include viewing PC monitor for extended amount of time.
• Ability to enter data and work with medical records using hand/wrist dexterity.
• Should be able to appropriately transport 25 pounds of medical records.
• Ability to sit at a computer for extended periods of time.
• Ability to walk or stand for extended periods of time.
• Ability to bend and stoop.
• Ability to travel to all facilities/campuses across the IDN.

Mental Demands:

• Ability to read and comprehend instructions, correspondence, memos, and electronic mail
• Excellent computer and skills with the ability to enter and retrieve data from electronic systems
• Strong written and verbal communication skills for professional interaction
• Must be detail and accuracy oriented.
• Ability to work independently and maintain focus on the scope of work assigned.
• Must be self-sufficient, not needing to rely on others to complete a job.
• Ability to coordinate and use logical reasoning to prioritize tasks and manage multiple tasks simultaneously
• Initiative independently takes prompt proactive steps toward problem resolution.
• Analytical skills effective evaluation, synthesis and use of information gathered.
• Must be able to work under potentially stressful situations with time constraints
• Ability to use critical thinking and problem solving skills to carry out all job functions and responsibilities
• Emotional intelligence recognize and understand emotions and use this awareness to successfully manage yourself and your relationships with others.

Benefits

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.

Schedule: Per Diem

Shift Times: 8:00am-4:30pm

Paygrade: PG-28