Medical Records Specialist

Schedule

Full-time: 40hrs/week

Hours: Monday - Friday, 10:00 am - 6:30 pm

Occasional weekends/holidays

General Duties:

Position Function: Under the direction of the HIM Manager, assembles, files and retrieves medical records, maintains chart location system, analyzes, unitizes, answers phones, purges for microfilm, and scans patient records (batch prep, acquisition, indexing, quality assurance, etc.).

Essential Functions and Responsibilities
Unit Based Essential Functions and Responsibilities

Core Values: Service, Integrity, Compassion
1. Demonstrates service excellence and patient and family centered care by showing respect, honesty, fairness and a positive attitude toward all customers.
2. Maintains confidentiality.
3. Demonstrates dependability, to include attendance and punctuality.
4. Is accountable - takes initiative and ownership of issues.
5. Displays a professional demeanor. Represents hospital in a positive way. Has a compassionate working relationship with patients and families.
6. Assumes personal responsibility for 2-way communication. Communicates and listens effectively with patients, families, coworkers, other departments, physicians/providers and community.
7. Supports coworkers, initiatives and a patient and family centered philosophy; pitches in; does own part and helps others.
8. Works to continuously improve work environment/processes (Performance Improvement). Demonstrates a patient and family centered focus when considering/developing improvement solutions.
9. Represents willingness/enthusiasm to create, embrace and facilitate change.
10. Develops self and others; supports a learning environment; leads by example. Encourages patients and families to give feedback and suggestions for improvement.
11. Develops working relationships critical to the organization including patients, families, coworkers, other departments, physicians/providers and community.
12. Encourages others by providing recognition and support.

Technical Excellence
1. Thinks critically; utilizes sound judgment; promptly reports potential risks.
2. Maintains state of art knowledge of area of specialty, healthcare trends and practice, and populations served.
3. Maintains a level of computer literacy appropriate to their role.
4. Meets and maintains current all unit specific and organizational skills/competencies, certifications/licensures, as required.
5. Completes hospital-required reviews, e.g. HIPAA, safety, health screening,
care concerns, and others as assigned.
6. Adheres to National Patient Safety Goals.

Job Class Specifics
1. Unless excused, attends all departmental in-services and educational programs to develop new skills and maintain competencies.
2. Assists with orientation and training of new staff, students and volunteers as assigned.
3. Meets and maintains established productivity standards.
4. Completes a daily activity log and submits it to immediate supervisor at the end of each week.
5. Plans and prioritizes workload at the beginning of shift and throughout shift in accordance with departmental goals, turnaround time standards, objectives, etc. so that deadlines can be met.
6. Maintains knowledge of record assembly order.
7. Pulls records and assists physicians in the incomplete area as requested. Updates record deficiencies in the Meditech system appropriately.
8. Checks miscellaneous reports daily, verifying the medical record number, account number, name, dates, etc., for accuracy.
9. Immediately notifies HIM Manager of any lost or missing records.
10. Prepares specified records in files for back scanning per back scanning procedure.
11. Collects discharge records from nursing units daily. Assembles records according to written procedure, attaching miscellaneous reports to records accordingly, and places records in file folders by last 2 terminal digits on the shelf labeled by discharge date.
12. Analyzes records according to the Medical Staff Bylaws, The Joint Commission and DOH requirements, entering deficiencies into the Meditech system and attaching miscellaneous reports to the record.
13. Batch preps records according to established guidelines, keeping like forms together, verifying patient name, account number and medical record number.
14. Reviews medical records upon completion by the medical staff (as assigned) and updates ICR Routines in Meditech.
15. Assures accuracy of patient information through verifying patient name, date of birth, medical record number, etc.
16. Assists with telephone coverage. Directs departmental calls and requests for medical information. Answers phone promptly and professionally within three rings, stating name and department. Responds or refers calls as necessary, takes complete phone messages to include caller, data and response requested. Greets visitors, physicians and staff in a positive, congenial manner.
17. Receives requests for outpatient and inpatient information. Obtains proper authorization and identification prior to release of information. Understands and adheres to all guidelines on release of information outlined by departmental policies and procedures and electronic Release of Information Manual. (HIPAA and HIM)
18. Uses desktop faxing to send requested copies of medical records to physicians/offices or other health care providers upon request.
19. Demonstrates knowledge of various departmental jobs and office equipment (i.e., microfilm reader, printer, copier/fax machine, computer applications; maintains ability to assist in other positions).
20. Performs the following scanning operations. (Batch Prep, Acquisition, Indexing, QA, etc.)
21. Maintains patient confidentiality at all times.
22. Processes and prints PCS in accordance to the policy and procedure. Reports any issues to the HIM manager immediately.
23. Offers the patient portal to customers when appropriate, completes required paperwork appropriately, enters patients into the patient portal, and saves portal proxies to the P: drive.
24. Performs other duties as required or assigned by the HIM manager.

General Requirements

The following requirements are expected of all employees:
Core Values: Integrity, Compassion, Excellence, Service
Annual Health Screening with Infection Control and Blood Borne Pathogens Education
Safety Awareness: Hospital Fire, Safety, and Disaster Procedures
Confidentiality: Maintains Employee and Patient Confidentiality
Attendance: Regular attendance is an essential function of the position
Leadership Standards:
Character: Attitude, Integrity, Role Modeling
Job Performance: Results Orientation, Customer Focus, Decision Making, Awareness
Interpersonal Skills: Communication, Relationship-building, Team Player, Celebration
Innovation: Breakthrough Thinking, Knowledge-Building/Sharing, Coaching/Empowering, System Vision & Management

Physical and Mental Requirements: Classified as medium work by the Dictionary of Occupational Titles; may exert 20 to 50 pounds of force occasionally, and/or 10 to 20 pounds of force frequently, and/or greater than negligible (up to 10 pounds) force constantly in order to move objects. Ability to travel stairs up to 30 times per shift.
- Stands frequently on carpet, tile or linoleum during a normal shift.
- Walks throughout the department and hospital.
- Sits occasionally on a hard or cushioned chair.
- Lifts and carries up to 30 pounds occasionally to and from all levels.
- Carries up to 15 pounds frequently.
- Pushes/pulls up to 30 to 40 pounds on an occasional basis.
- Frequently bends, squats, and kneels from an upright position to lower levels.
- Frequently twists from the upper torso.
- Reaches to heights of up to two feet overhead frequently.
- Manual dexterity and digital sensitivity adequate for utilizing a variety of equipment.
- Ability to move rapidly in response to unpredictable emergencies that could happen one or more times per shift.
- Near visual acuity necessary deciphering fine print; must be able to work in confined, dimly lit area.
- Auditory acuity with ability to hear phone conversation, overhead pages, alarms, and normal voice tones when not facing the individual.
- Good hand/eye coordination.
Mental Demands Ability to communicate in both written and verbal form in order to take notes/minutes of meetings, take dictation, and relate to staff and others; ability to speak, read, and write the English language; ability to efficiently and effectively handle multiple demands simultaneously as a result of working under the pressure of deadlines.

Working Environment: Work is performed in a clean, well-ventilated, indoor environment. May require sitting or standing for uninterrupted periods of time.

Reporting Structure: Formal Reporting and Chain of Command: Reports to HIM Manager. In his or her absence, reports to the Director of Health Information Management.

Informal Reporting and Relationships: Establishes and maintains positive working relationships with co-workers, medical staff and the public. Is expected to work in a team fashion with other clerical staff to meet productivity standards, as well as other HIM staff to achieve departmental goals.

Disclaimer: These essential job functions are requirements of the position which must be performed either with or without reasonable accommodation. The essential job function list is intended to be a guide rather than a limitation. The Chambersburg Hospital possesses the right to add new responsibilities to the list as business demands dictate. Some of the essential job functions may exclude individuals who pose a direct threat/significant risk to the health and safety of themselves or others.

By identifying essential job functions, we are in no way stating or implying that these required tasks are the only activities that are to be performed by the employee occupying this position. In addition, employees will also be expected to follow any other job-related instructions and to perform any other job-related duties that are included in the job description. The preceding requirements represent only the minimum acceptable levels of knowledge, skills, and/or abilities that a job incumbent must possess; to perform the job successfully, the incumbent will possess additional aptitudes to perform the other duties that the job description entails.

Qualifications and Standards

Education: Formal Education and Training:
- High School graduate or equivalent with at least one year of medical records or physician office experience.
- OR a student who is currently enrolled in an accredited Health Information Management program.
- OR a graduate of an accredited Health Information Management program.

Informal or Continuing Education: None Required

Experience: Experience applying customer service behaviors and communication skills required. Ability to operate a ten-key keypad. Knowledge of Word and Excel preferred.

Certifications/Licensure: None required.