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Form of workUnder general supervision, to perform a variety of complex medical record clerical activities requiring a high level of discretion and judgement.
This recruitment will be used to fill current full-time/part-time positions and extra help (temporary) assignments at various HIMS departments located throughout Health & Hospital System.
If you are interested in extra help opportunities, please be sure to indicate that on the appropriate questions.
- Obtains, reviews and analyzes medical records for completeness, identifies discrepancies or incomplete work and places deficient records in a file assigned to physicians for completion;
- Performs data entry of record deficiencies as indicated;
- Monitors status of incomplete record work, calls to remind physicians of incomplete work, tracks the location of incomplete records, and sends records left incomplete by departed interns and residents to the appropriate Chief of Service;
- Prepares completed records for permanent medical records files;
- Transfers requested medical records information to forms such as disability or categorical welfare applications and submits them to staff physicians for completion of medical statements;
- Maintains, researches and corrects all information for incorrect record numbers or double number patients and processes/merge all double numbers and related paperwork appropriately and in a timely fashion;
- Performs extended record or information searches and works toward successful location of most lost files in a timely manner;
- Proofreads computer input and output to ensure correctness of entries and reviews rejected entries to identify and correct errors;
- Performs advanced information system reconciliation;
- Trouble shoots day to day issues in a responsible manner;
- Releases or processes patient information and legal documents correctly according to current applicable State and Federal regulations, and written procedures, and seeks supervision or consultation when uncertain;
- Completes patient information forms including those for state disability, DMV, Employment Department, Department of Rehabilitation and Social Services, WIC, and school and other physicals;
- Interviews parents or family members in order to obtain information needed to prepare official birth or death certificates, and obtains required signatures of parents, family members and attending physicians;
- Prepares and completes records, certificates and statistics of all births and deaths at the hospital;
- Reviews patient records for cause of death and any medical or other indications that a death may be a Coroner's case;
- Reviews the physicians statement on death certificates to insure it is acceptable for filing by the Health Department;
- Checks autopsy forms to insure that the physician has completed them in the required manner;
- Assists families with questions about death or autopsy reports to contact attending physicians;
- Operates a variety of office equipment such as computer terminals, calculator, fax, copier, patient information and image management systems, and other modem medical office machines, and performs routine operations such as adding computer paper, changing toner cartridges, and printer ribbons;
- Orients or guides lower level employees;
- Types forms and correspondence;
- Performs other related duties as required.
Experience Note: The knowledge and abilities required to perform this function are normally acquired through successful completion of 1) college level medical legal course work and two years of medical record processing experience or 2) graduation from an accredited Health Information technology program or equivalent. Some positions may also require one year of data entry experience.
Knowledge of:
- Medical terminology and standard abbreviations used in medical notations;
- Basic anatomy preferred;
- Computer skills, including accessing and retrieving computerized data;
- Computer software and a working knowledge of data entry;
- Current JCAHO/Title 22 compliance requirements regarding medical records standards;
- State and federal laws pertaining to confidential, privacy and security of patient information and the requirements for release of patient information;
- Commonly used state forms such as state disability, Department of Rehabilitation, WIC, schools handicapped or other request forms for physicals;
- Current version of medical coding structures;
- Principles of public relations;
- General office practices and procedures;
- Modern standard office machines including computers, scanners, fax, copier, calculator and typewriters.
Ability to: - Follow set standards accurately in checking complex data in records for completeness and internal consistency;
- Read and understand medical terminology to the degree necessary to insure correctness of format and consistency in the general contents of a medical record;
- Work independently and exercise initiative, judgement, and tact in searching for missing data or documents and in dealing with staff or outside physicians, insurance companies, attorney's and other public and private agencies;
- Prepare statistical reports, maintain logs, files, and computer data files;
- Screen patient information from medical records for completion and abstraction of various forms;
- Learn, understand, and apply complex levels of confidentiality, privacy, security for the protection and disclosure of release of patient information;
- Safely perform physical activities such as:
Reaching over one's head and bending down to retrieve files;
Standing, sitting, pulling records, and/or walking for long periods of time;
Periodic lifting moderately heavy file containers;
Pushing heavy carts (may be required for some positions); - Establish and maintain effective working relationships with all levels of medical, professional, administrative and support personnel contacted in the course of work.
