::. PRIMARY RESPONSIBILITIES
Provide guidance to physicians/licensed practitioners and facility personnel in completion of medical records, ensuring compliance with all laws, rules and regulations of federal and state licensing agencies, and within the TJC standards for the quality of patient care.
Audit patient information/medical records for accuracy and appropriateness.
Perform medical record admission procedures to include maintenance of the master patient index and hard copy files for accuracy and organization. Resolve discrepancies as necessary.
Perform medical records discharge procedures to include maintenance of the master patient index and analyzing medical records for accuracy and completeness. Resolve discrepancies as necessary.
Maintain medical records deficiency logs, updating status of delinquent records.
Ensure the confidentiality of patient records is maintained per HIPPA and State regulations.
Answer inquiries from internal and external contacts regarding information recorded in the patient's medical records, within all departmental policies and guidelines.
Assist with responding to subpoenas, and other legal requests pertaining to medical records, as requested by the Director.
Code discharged patient charts using appropriate coding ICD-9/10 guidelines, and abstracts all pertinent patient information for forwarding to state agencies as required.
Notify the Director regarding any potential problems with record updates, maintenance and/or breaches of confidentiality and customer service issues.
Accurate filing within the record and according to terminal digit filing for inactive records.
Juggle daily tasks while answering phone and other external requests.
Provide release of information services.
Maintain the organization and efficiency of the HIM Department's services.
Take on additional responsibilities as directed by supervisor or the needs of the department.
Typing speed of at least 70 wpm required. May be required to work occasional overtime and flexible hours. Ability to utilize Microsoft Office Suite (Excel, Word, Access, Outlook). Have the comfort level to learn and navigate hospital data systems.
EDUCATION and/or EXPERIENCE
Education: Graduate from a Health Information Management program preferred; high school graduate or equivalent with some college courses required.
Experience: At least two (2) years experience in health care information management/medical records and a thorough knowledge of medical terminology required. Familiarity with ICD 9/10 coding.
Ability to communicate effectively office policies and procedures to parents/guardians, physicians, aftercare providers and other customers.
Ability to work independently with minimal supervisor intervention. Ability to screen priorities and situations that require resolution from the supervisor. Proficiency in service recovery.
CERTIFICATES, LICENSES, REGISTRATIONS
Universal Health Services