Job Summary: Supervises routine medical record-keeping operations and healthcare information management to ensure secure, accurate, and reliable patient information management that complies with date and privacy regulations. Follows established policies and procedures to ensure effective and compliant record management, makes suggestions for process improvements.
DUTIES AND RESPONSIBILITIES:
Asist in establishing and implementing written policies and procedures.
Assist in organizing, planning, and directing the medical records department in accordance with established policies and procedures.
Assist in the orientating program for all personnel in accordance with policies and procedures.
Assist the medical records consultant as required.
Prepare necessary quality assurance studies and direct to Medical Staff.
Prepare follow-up of meetings/studies as necessary.
Collect, assemble, check, and file patient charts and records as required.
Assure that all charts are completed by physicians within established time frame.
Assure that coding of outpatients and inpatients is done in a timely manner.
Assure that necessary monthly, quarterly, and annual reports to State Department of Health are completed and sent out.
Check discharges each day.
Check transcription of Medical Records Clerk as needed.
Assure that current dictation is typed each day and put on patient charts.
Assure that all chart dictation is typed within 24 to 48 hours.
Participate in Medial Staff monthly meetings. Direct to the attention of Medical Staff any unusual or interesting materials.
Obtain all necessary recertifications for insurance.
Ensure that charts/records do not leave the area except as authorized. Maintain a record of authorized information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
Check carts for completion for review by PRO/Medicare and DRGs.
Set up Tumor Registry and keep current.
Ensure incomplete records/charts are returned to nursing services and other departments for correction and/or completion.
Report equipment malfunctions or breakdowns as soon as possible.
Ensure supplies have been replenished in work areas as necessary.
Ensure that schedules are followed as outlined.
Asist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
Abstract information from records as authorized/required for insurance companies. Medicare, etc. Collect and assemble/compile records for committee review as requested and prepare reports for staff/other committees as directed.
Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
Attend and participated in workshops, seminars, on-the-job training, etc., to keep abreast of current charges in the health care field, as well as maintain a professional status.
Assure that patient’s rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints, are followed.
Record all incidents/accidents, unsafe/hazardous conditions, defective equipment, etc. in accordance with established policies and procedures.
Follow established safety/disaster and infection control policies and procedures. Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.
Maintain CONFIDENTIALITY of all pertinent patient care information to assure patient rights are protected.
Assure that work areas are clean and office equipment is properly covered before leaving suck areas at end of workday.
Other related duties as may become necessary or as directed by the Administrator.
Professional Requirements:
Adheres to dress code, appearance is neat and clean.
Completes annual education requirements.
Maintains regulatory requirements.
Maintains patient confidentiality at all times.
Reports to work on time and as scheduled, completes work within designated time.
Wears identification while on duty; uses computerized punch time system correctly.
Completes in services and returns in a timely fashion.
Attends annual review and department in services, as scheduled.
Attends staff meetings annually.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Complies with all organizational policies regarding ethical business practices.
Communicates the mission, ethics and goals of the facility, as well as the focus statement of the department.
Regulatory Requirements:
Language Skills:
Skills:
This institution is an equal opportunity provider and employer.
Job Type: Full-time
Pay: $26.00 – $32.00 per hour
Benefits:
Schedule:
Work Location: One location
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