Job Responsibilities: Primary Job Functions:
- Receives and processes all requests for health records from file area after consumers' discharges.
- Reviews and analyzes medical records for accuracy, completion, and timeliness of documentation.
- Assembles record in chronological order during review, and prepares record for imaging.
- Checks and documents all chart deficiencies: for nurses, doctors, therapists and behavioral staff (Inpatient), and completes Administrative Reviews (Outpatient).Correctly categorizes deficiencies based on color coding system in use.
- Obtains all missing information and corrects all deficiencies in records within standard compliance timeframes.
- Protects and maintains the confidentiality of all records and patient information.
- Maintains the chart tracking (charge-out) system to track the location of each record.
- Assists clinicians with pulling and locating charts.
- Sorts incoming charts and ensures they are routed to the proper location and clinician.
- Ensures charts are filed back promptly by the end of each workday.
- Completes and processes authorizations to release of information as requested.
- Answers the telephone in a professional manner using 5 Star Customer Service standards.
- Orders, maintains, and distributes AltaPointe approved forms.
- Assists in purging records for destruction on a regular basis.
- Adheres to program specific procedures and protocols as outlined by the Assistant Coordinator of Health Information.
- Supervision and Consultation:
- Seeks supervision and consultation as needed
- Accepts and employs suggestions for improvement
- Actively works to enhance skills.
- Courteous and Respectful Behavior:
- Treats consumers with care, dignity and compassion.
- Respects consumers' privacy and confidentiality.
- Works in a cooperative manner with other AltaPointe employees.
- Assists consumers and visitors as needed.
- Personal values don't inhibit ability to relate and care for others.
- Is sensitive to the consumers' needs, expectations and individual differences.
- Is gentle and calm with consumers, families, and others as appropriate.
Administrative Duties:- Actively participates in Performance Improvement activities.
- Actively participates in AltaPointe committees as required.
- Completes assigned tasks in a timely manner.
- Follows AltaPointe policies and procedures.
- Attends appropriate in-service training and other workshops.
- Other duties as assigned.
- Physical Requirements of the Job:
- Continuous sitting (extended sitting) up to 2 hours at a time until break or lunch.
- Reaching forward to place paperwork on a document stand.
- Grasping to turn keys in doors throughout facility, grabbing files/paperwork.
- Lifting up to 10 pounds.
- Carrying up to 10 pounds to transport small quantities of charts various distances in facility.
- Fine manipulation/dexterity for data entry, writing and handling paperwork
- Standing and walking frequently throughout shift and to various locations in the facility to file charts and put up supplies.
- Sitting can be in frequent bursts up to 10 minutes.
- While filing in the medical records department, the employee may bend forward, squat, lunge, stoop or crouch to access the levels that are at floor to waist level.
- Forward reaching, reaching out to front, and overhead reaching with up to 5 to 15 pounds is performed when filing records and charts.
Qualifications:
High school graduate or the equivalent; two to three years' experience in a medical records department or health care office setting; knowledge of medical and psychiatric terminology; ability to communicate verbally, withstand continual deadlines, concentrate and maintain accuracy in spite of frequent interruptions; detailed oriented and highly organized; knowledge of the following must be demonstrated within 6 months of hire:
- Understanding of documentation requirements and procedures in compliance with key agencies that include, but are not limited to, CMS, DMH and The Joint Commission
- Basic clerical skills including Microsoft Office, and the principles of alphabetic, numeric, and terminal digit filing
- Use of standard office equipment including copy machines and fax machines, and
- General EHR and medical records procedures and standards.
