Medical Record Clerk II

4 weeks ago

Wailuku, United States Kaiser Permanente Full time
Job Summary:
Under direct supervision, supports all scanning and indexing activities for region.

Essential Responsibilities:

  • Processes and ensures a variety of medical, business, and organizational documents are stored in an electronic scanning system as appropriate.
  • Prepares, scans, evaluates, and indexes information stored in an electronic scanning system in a timely manner.
  • Evaluates information and reports discrepancies as necessary.
  • Opens all incoming departmental mail. Identifies and sorts all documents. Prepares documents for scanning. Initiates batch control coversheet with appropriate information. Identifies indexing elements such as Medical Record Number (MRN), date of service, encounter type. Retrieves information from a variety of computer systems to complete indexing tasks.
  • Accurately indexes standard and non-standard documents.
  • Performs a variety of clerical duties according to established procedure. Pulls and distributes patient charts upon request from authorized personnel. Collects and returns to offices or requisition point. Checks charts for completeness and acceptable physical condition. Sorts and refiles charts. Files medical and other pertinent data required for completeness. Re-routes charts electronically from one destination to another. Locates and corrects misplaced or misfiled charts. Notifies requestor of chart non-availability. Maintains security and confidentiality of sensitive patient information. Exchanges old folders for new. Types labels as needed. Corrects labels upon notification of patient I.D. changes. Enters data in computer.
  • Accesses and retrieves scanned images/documents from retention boxes, paper charts, digital archive, or other database during electronic medical record downtime.
  • Prepares documents for digital archiving. Performs standard digital archiving into an electronic digital archiving system.
  • Verifies member/patient demographic information as appropriate. Corrects discrepancies according to procedures. Forwards complex discrepancies to senior staff for resolution.
  • Batches, counts, and scans all incoming documents and a variety of medical, business, and organizational documents into electronic scanning system as appropriate. Performs visual quality review of scanned images to ensure integrity of information by reconciling all documents available on paper to imaged counterpart. Performs or redirects scanning as necessary. Records each step in process for purposes of accountability. Assures conformance to service level agreement.
  • Reviews all incoming medical, business, and organizational documents. Identifies documents for scanning or filing. Recognizes and processes high priority documents according to regional policies. Distributes documents appropriately. Assists with problematic documents and reroutes misdirected documents according to procedure.
  • Performs standard indexing into an electronic scanning system using copy/paste techniques or shortcuts as designated by department.
  • Evaluates information stored in an electronic scanning system for accuracy and adherence to departmental guidelines as part of Quality Assurance check and reports discrepancies as necessary. Performs pre or post scan quality assurance validation of documents. Enters errors in database and performs corrections/reconciliation.
  • Prepares historical charts for digital archive; uploads to digital archive and notifies clinicians of availability. Performs quality assurance checks on digitally archived and/or uploaded charts and resolves discrepancies.
  • Enters various clinical data information from medical documentation relating to clinical diagnosis, medications, hospital admissions, immunizations, and other pertinent patient clinical information for patient database records.
  • Analyzes inpatient and designated hospital-based outpatient records for documentation deficiencies. Follows medical staff by-laws, reimbursement requirements and The Joint Commission standards relative to completion of medical records. Identifies deficiencies and discrepancies.
  • Re-analyzes records upon completion of deficiencies by medical, nursing and ancillary staff. Notifies practitioners on delinquent/incomplete records. Ensures timely completion of medical records.
  • Performs medical record reviews. Summarizes and reports results of reviews to hospital administration, medical staff, and Health Information Management Committee. Assists physicians with chart completions when necessary.
  • Maintains departmental databases, such as indexed batches, back-up indexed documents DVDs, and indexed documents errors database. PROVIDES assistance to users of departmental databases.
  • Maintains patient confidentiality. Identifies discrepancies of medical records documentation. Obtains data from other Kaiser systems. Compiles and organizes information for fellow staff and generates reports.
  • Maintains solid knowledge/understanding of HIPPA privacy and security issues as it relates to release of information, and/or other regulations related to protected health information.
  • Assists users of imaging system to successfully access information and navigate through the system. Refers more complex questions to appropriate staff. Researches paper and electronic resources to support system users. Researches and problem solves user requests or issues as appropriate.
  • Retrieves documentation from electronic medical record or paper medical record. Forwards to requestor as appropriate.
  • Operates and monitors equipment properly (e.g., personal computers, scanning devices, fax machines, etc.). Coordinates repair when necessary.
  • Compiles and records data for routine or special reports.
  • Performs variety of clerical duties according to established procedure and needs
  • Assists in orienting and mentoring JR staff. Provides input to Data Specialist of employees performance. Assures departmental and organizational qualities of service standards are upheld. Works with fellow senior staff in identifying potential and existing barriers to maintain standards. Works with Data Specialist and Supervisor and other staff to review and develop procedures. Assists in monitoring results. Recommends changes to ensure effectiveness and efficiency.
  • Meets with other senior staff to discuss common problems and issues and share best practices. Attends meetings that affect functioning of team. Communicates and educates Clerk IV and III as to policies and changes. Ensures Clerk IV and III understands policies and changes.
  • Advises Data

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