Job Summary

This position prepares the medical record for completion by physicians and other allied health care professionals. Abstracts information from the medical record which provides an accurate data base of pertinent information relating to the patient's care.

Reports to: HIM/Coding Manager

Essential Job Functions

• Assembles and analyzes patient's record after discharge.

• Files all documentation in the medical record.

• Assists with telephone and reception needs as necessary.

• Maintains proper confidentiality of medical records and ensures limited access to the department.

• Follows all applicable laws and regulations regarding the release of information and the maintenance of medical records, including those that relate to the age and legal status of the patient.

• Prioritizes work assignments and accomplishes tasks accurately and in a timely manner.

• Utilizes automated processes and clinical information systems appropriately and efficiently.

• Demonstrates the spirit of the philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment.
  • Applies the principles and values of customer service and continuous quality improvement while performing day to day activities of the position.
  • Maintains and protects confidentiality regarding all aspects of patient care, personnel and strategic issues. Adheres to Confidentiality Policy.
  • Maintains positive working relationships and fosters cooperative work environment. Adheres to the hospital’s Guidelines for Appropriate Conduct in the HR Manual.
  • Displays honesty and mutual respect when communicating with peers and other departments.
  • Follows through on problems that may compromise effective job performance by using appropriate chain of command.

• Utilize concepts of age/developmental stages in interactions with patients and families.

Minimum Requirements

Education: High School Diploma or the equivalent.

Certification, Licensure: RHIT, RHIA, CCS certification, or eligible preferred.

Experience, Training, Knowledge: Requires knowledge of medical terminology; previous experience in Health Information Services in the healthcare industry preferred.

Physical Requirements

This position requires lifting, carrying, pushing, and/or pulling up to 10 pounds. Stooping, kneeling, crouching, reaching, grasping, handling, and balancing 5 or more hours per day. . Sensory and communicative activities including: hearing, seeing, and speaking to be able to carry out essential job functions. Must be able to read and write English. Must be able to differentiate between all ranges of color.

Working Conditions/Environmental Exposures

Normal office environment. Hazards are minimal if safety precautions are taken. Protective clothing/equipment normally not necessary.