Health Information Management

4 weeks ago

Santa Rosa, United States Northern California Behavioral Health System Full time
Job DescriptionJob Description

KEY RESPONSIBILITIES:

· Run daily AIS reports to validate and account for patient discharges, both Inpatient and Outpatient.

· Pull charts for review and analysis on a timely basis as required by policy and by regulation.

· Assemble and analyze discharged patient charts and review Inpatient and Outpatient records according to department standards.

· Responsible for managing patient health records.

· Identify chart deficiencies for missing details (i.e., Protected Health Information, signatures, dates, times, and details) and charting.

· Document deficiency findings using the deficiency tools in software and on corresponding audit forms.

· Enter deficiencies into AIS.

· When charts have been completed by the physician or midlevel, reanalyze the pt charts for accuracy and remove deficiencies from AIS accordingly.

· Create and maintain patient charts based on established department guidelines.

· Ensures medical records are assembled in standard order and are accurate and complete.

· Assist in retrieving charts for stakeholders for chart completion.

· Retrieve and re-file the patient’s medical records, as needed.

· File loose filing daily into the proper charts. Prepare charts for patient discharge process.

· Creates or scans digital images of photos, forms or records to be included in the electronic medical record.

· Responds to requests for patient records, both within the facility and by external sources, retrieving them and transmitting them accurately, timely, and appropriately.

· Process all requests for medical records received by mail, fax, or phone according to State and Federal requirements.

· Ensure that the release of information is completed properly, timely, and valid.

· Collaborate with other departments to gather records needed to ensure timely and compliant billing.

· Assist in answering telephone and taking accurate messages.

· Pulling charts for physicians, nursing and other hospital personnel.

· Perform audits as requested.

· Assist in processing dictated and/or transcribed reports.

· Print reports as needed for timely inclusion into the patient’s active medical record.

· Work with the physicians, midlevels, and other hospital personnel to answer questions regarding dictation or transcription.

· Ensures that errors by outsourced transcription company are corrected and sent to the document’s author for review and signature.

Requirements

Knowledge and Experience:

· High school diploma or equivalent.

· One year of experience working with medical records preferred.

· Coursework specific to regulations pertaining to proper administration of medical records preferred.

· Demonstrated knowledge of patient privacy and security, HIPAA, CMIA, and LPS relative to maintaining medical records required.

· Knowledge of medical terminology preferred.

Skills and Abilities:

· Promote patient, physician, customer and employee satisfaction by personal example, treating all contacts with respect

· Support and participate in activities that foster customer service

· Communicate and follow the organizational chain of command for notification of patient care/service issues, when appropriate

· Maintain a complete knowledge base of record completion requirements

· Maintain consistent productivity and quality of work in a challenging, fast paced and rapidly changing environment

· Closely adhere to set schedules and timecard procedures

· Identify, resolve and escalate major issues and service failures that impede success

· Maintain confidentiality of all patient demographic, medical, and financial information, ensuring proper handling and disposal of confidential documents and adherence to HIPAA

· Comply with all applicable Federal, State, and local laws, regulations, and requirements as well as PH&S policies and procedures in all aspects of job performance

· Attend and successfully completes general and department orientation, in-service programs and the annual key competencies and mandatory update requirements

· Participate actively in department staff meetings

· Demonstrate effective verbal and written communications

· Communicate effectively in all interactions in a clear, concise, understandable manner.

· Actively seeks constructive feedback and remains open and receptive to it

· Anticipate the information needs of others

· Demonstrate competency by maintaining positive, constructive interpersonal relationships, and by understanding and practicing the principles of effective teamwork

· Take responsibility to support team members in meeting project milestones and objectives.

· Perform challenging tasks efficiently and effectively

· Show strong, meticulous attention to detail and excellent analytical skills

· Demonstrate performance by adhering to established policies and procedure and exhibiting the defined characteristics associated with attendance and punctuality

· Monitor work queues and perform problem resolution/corrective action where needed

· Analyze medical records for completeness and compliance

· Assign documentation deficiencies to the correct physician, nursing, or other hospital personnel

· Process, scan and index medical records for accuracy, completeness and compliance into the correct paper or electronic medical record

· Confirm authorizations for release of information for requests as necessary

· Respond to business office requests for information and copies of specified documents

Physical Requirements:

While performing the duties of this job, this position is frequently required to do the following:

· Use standard office equipment and access, input, and retrieve information from a computer. Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.

· Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.

· Frequent bending, squatting, kneeling, climbing with the use of a step stool and twisting. Lift and carry up to 20 pounds.

· Sit or stand for minimum periods of one hour at a time. Come and go from the work area repeatedly throughout the day.

· Give and follow verbal and written instructions with attention to detail and accuracy.

· Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.

· Vision: see details of objects at close range.

· Coordinate multiple tasks simultaneously.

Benefits

  • Medical
  • Vision
  • Dental
  • 401(k)
  • 3.5 Weeks Paid Time Off
  • $25,000 Life insurance policy is provided at no charge to the employee

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