Job Title: Health Information Services Clerk II
Department: HIM 840
Reports To: CCOC Health Information Management Services Supervisor
Prepared Date: 7/22/10; 5/22/12
The HIS Clerk II trains all incoming staff on preparation, scanning and analysis of the HIM Department. HIS Clerk II acts as a supervisor of all HIM systems, including but not limited to HMS, Dictaphone, EWS. HIS Clerk II performs quality assurance audits on a weekly basis to verify the accurate assignment of deficiencies. The HIS Clerk II monitors quality of work performed by HIS Clerk I. Involved in all aspects of the continuous development of analysis, electronic medical records and deficiency functions.
ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES
Includes the following but are not limited to:
Processes requests for medical records according to hospital policies and procedures and consistent with HIPAA regulations
Generates post-discharge reports to be utilized for medical record pick up and tracking.
Retrieves inpatient and outpatient medical records according to discharge log.
Tracks all discharges against daily discharge list to identify missing records; informs appropriate personnel of missing records.
Reports Master Patient Index errors to Medical Records Supervisor.
Assembles medical records according to the specified chart order.
Identifies chart deficiencies accurately according to the Chart Deficiency policy and enters deficiencies accurately in the Chart Deficiency system.
Creates and organizes paper medical record folders and documents.
Retrieves hard copy medical records.
Files miscellaneous/late reports in the medical record.
Answers the telephone and responds to inquiries or routes inquiries to the appropriate person.
Assists physicians with questions or issues concerning medical records and/or medical record completion.
Checks in/out medical records in the Chart Tracking system.
Meets department/hospital guidelines for appropriate turn around time of record processing.
Performs analysis of medical records to assure all documents have correct patient labels, medical record numbers, visit numbers, and visit dates.
Performs analysis of medical records to assure physician completion on required entries
Performs analysis of medical records to assure completion of legal record
Assists Supervisor with training and orientation of new personnel.
Participates in departmental meetings and in-service education.
Maintains and updates the Imaging Procedural and Forms manual in cooperation with the Supervisor.
Communicates with appropriate hospital departments or external vendors for equipment maintenance as needed.
Operates scanning equipment effectively and efficiently; follows procedures for scanning of medical records; performs quality analysis of scanned images to assure readability; rescans documents as needed.
Performs other job related activities.
Prepares charts for internal and external audits.
Assists various departments with questions and documentation needs.
Adheres to policies and procedures contained in the CCOC Employee Manual
Follows HIPAA, JCAHO, and Compliance Plan regulations
Other duties as assigned
Performs final Quality Analysis of records prior to purge
Assists supervisor with bill select error reports
Audits inpatient and outpatient surgical accounts for accurate assignment of physician deficiencies, prepping and scanning based on the criteria established by the CCOC
Assists with calculation of productivity rates for HIS Clerks and updating processes and standards of which the HIS Clerk adheres to
Monitors and corrects the prepping, scanning and analysis errors and assists with additional training if needed
Coordinates training and performance improvement for probationary staff
Trains all allied health professionals credentialed with the CCOC on: HMS, EWS, Dictaphone and dictation, completion of paper records, etc
Acts as a supervisor for HMS, Dictaphone, EWS
Coordinates weekly medical staff notice for impending suspension or incomplete record notices
Reports to manager with delinquency rates, reports and charts as necessary
Completes special projects as assigned by manager
May participate in interview and selection of new candidates
Participates in department meetings
Assists and works in imaging, analysis and file room functions
Keeps manager informed on key issues.
Other duties as assigned.
Works well with patients, physicians, vendors, sales reps and other CCOC employees.
Successfully meets Unit Specific Skill Sets
Complies with all Standards of Behavior set forth by CCOC
Adheres to policies and procedures set forth in CCOC Employee Manual
Adheres to the CCOC attendance policy
Follows HIPAA, OSHA and Compliance Plan regulations.
An individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
High School diploma or equivalent
RHIA or RHIT preferred
1 (one) year prior experience in medical office preferred
Medical terminology knowledge
Communicates effectively, verbally and in writing, with Physicians and other hospital users of Medical Records.
Demonstrates behaviors consistent with the Customer Service Policy.
Ability to effectively interact with patient/customers (i.e. neonates/newborns, children, adolescents, young adults, middle-aged adults, and geriatric adults, as applicable), with the understanding of their needs for self-respect and dignity.
Has excellent filing skills; terminal digit filing experience is preferred.
Has intermediate computer skills and the ability to operate business office equipment
Is an independent thinker and problem solver.
Is organized and detail oriented
Can prioritize work.
Can multi-task in a fast paced work environment.
Can interact appropriately with co-workers and create a supportive and team focused environment.
Can utilize and manipulate multiple software systems and applications.
Must have the dexterity to operate computer keyboard and basic office equipment
Must be able to sit or stand for extended periods of time
Must be able to stoop, pull and lift.
Must be able to walk for extended distance
As an organization, all employees with patient contact are expected to demonstrate competencies, specific to their job duties, for the following patient population categories:
Elderly, Children, Surgical, Impaired (Hearing/Visual), Cultural, Age.
NOTE: The above stated duties are intended to outline those functions typically performed by individuals assigned to this classification. This description of duties is not intended to be all inclusive or to limit the discretionary authority of supervisors to assign other tasks of similar nature or level of responsibility.
Crystal Clinic Orthopedic Center