Job Description

ECU Health

About ECU Health
ECU Health is a mission-driven, 1,708-bed academic health care system serving more than 1.4 million people in 29 eastern North Carolina counties. The not-for-profit system is comprised of 13,000 team members, nine hospitals and a physician group that encompasses over 1,100 academic and community providers practicing in over 180 primary and specialty clinics located in more than 130 locations.
The flagship ECU Health Medical Center, a Level I Trauma Center, and ECU Health Maynard Children's Hospital serve as the primary teaching hospitals for the Brody School of Medicine at East Carolina University. ECU Health and the Brody School of Medicine share a combined academic mission to improve the health and well-being of eastern North Carolina through patient care, education and research.
Position Summary

Under the supervision of the Health Information Management Services (HIMS) Manager and/or Supervisor and the overall supervision of the Director of HIMS, this demonstrates a commitment to excellence in patient and staff relations. As a member of the HIMS team and the HIMS Operations, this position aids in the management of medical records and assists with the timely response of medical record requests for external customers in the HIMS department. Copies records for Release of Information, accurately preps/scans/QA charts, performs necessary duties for Vital Records, resolves any duplicate medical record numbers and prepares deficiency/delinquency lists for physicians. This position is required to perform and complete any additional duties associated with the HIMS department in a quality, effective manner and assist the HIMS Manager and/or Supervisor as needed.
Responsibilities

1. Release of Information

• Responsible for sorting incoming mail into the department. All requests for records are stamped with date received.
• Responsible for the coordination and processing of release of Patient Health Information (PHI), including reviews to all requesters such as patients, physicians, other health care providers, insurance companies and attorneys via the ROI module within EPIC.
• Verifies authorizations and prepares records, documents items released, in accordance with hospital policy and state and federal laws. Contacts Risk Management as needed to ensure proper authorization.
• Processes RAC and/or MAC requests when received from the Office of Audit and Compliance. Scans paper records and converts electronic and paper records to .pdf format within specified time constraints.

2. Scanning

• Responsible for having the knowledge necessary to operate the appropriate scanners according to procedure.
• Responsible for knowing how to prep, scan, index and QA any record type according to the appropriate policy/procedure.
• Must be familiar and able to work the Record Corrections WQ's and the Index Exception Fix in Image Now.

3. Chart Completion

• Accurately processes and reconciles daily outpatient/discharged records.
• Maintains follow-up on records if they are not received after discharge.
• Assists with maintaining and following up on Pended Notes report to assure completeness of record.
• Perform analysis of Inpatient, Outpatient, Rehab, Emergency Department and Behavioral Health medical records via the imaging system.
• Reviews the medical record for all required documents and signatures according to regulatory standards depending on record type.

4. Vital Records

• Submits completed birth and fetal death certificates to Vital Statistics in Raleigh and the local Health Department within 5 days of birth.
• Maintains notary status to complete affidavit as needed.

5. Deficiency Tracking

• Works closely with physicians to ensure that all medical records are completed within 30 days or established time frame for each document type.
• Prepares and sends out weekly list of all providers having incomplete records.

6. Quality Control

• Participates in data collection as requested.
• Keeps work accurate and current at all times and notifies Manager and/or Supervisor when backlog develops.
• Assists in troubleshooting problems with any Software (Softmed, EHR, etc.).

7. Risk Management

• Demonstrates an understanding of the medico legal implications and responsibilities as relates to the maintenance of patient records to protect the patient and ECU Health.
• Provides strict control and confidentiality of medical record materials via computer and reception area and assists others in the department in maintaining the same control.

Minimum Requirements

• Associate's Degree is required or higher.
• Medical Terminology and computer experience preferred.
• One year of similar work environment experience preferred.
• Detail oriented, dependable and works well with others is a must.
• Able to understand the paper medical record as well as the electronic medical record.

Other Information

• Position is on-site.
• Work days for this position are Tuesday - Saturday.

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.
Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.
We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant's qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.