MEDICAL RECORDS TECH

Description

POSITION SUMMARY:

The purpose of this position varies, depending on the specific duties assigned; however, the main responsibility is to analyze the medical records for completeness, ensuring that all regulatory requirements are met. The main responsibilities include; review of each record type (IP or OP) for completeness and assigning deficiencies to the providers, as needed, and removing the deficiencies when completed. Other responsibilities may include; duties related to the Master Patient Index, oversight of the Physician suspension process, answering the telephone, document scanning, quality assurance, testing items in the EMR, etc.

• Completes Deficiency Analysis on all required medical records, collaborating with Scanning Technicians to ensure all records are received, scanned and processed.
• Performs Deficiency Analysis via Meditech on records for completeness and accuracy according to established standards (JC, State, MS R&R)
• Accurately assigns form IDs and electronic signature functions for all documents identified that need clinician signature
  
  

Timeliness: Within Four days of discharge

Quality: Ensure that all required reports, signatures, etc. are present or identified as deficient.

• Maintains accurate medical record “filing” within the Meditech MPI; including duplicate MRN investigation, service area inaccuracies, incorrect documentation on wrong account, etc. that are identified by HIM or by another department. This involves follow-up with ancillary departments and completion of the correction tool.
• Regularly runs Meditech reports to identify possible duplicate MRNs and, after investigation, merges any records accordingly. Notifies merges to other ancillary departments who maintain a separate registration system; and notifies RHIO according to their process.
• Performs all required Meditech functions as efficiently as possible and according to outlined procedure. Utilizes all applications for data retrieval, tracking, analyzing etc. (EMR/ELR).
• Is a key contributor with the implementation of new or revised documentation workflow in Meditech, by working closely with the IT analysts and department leaders, ensuring documentation is complete and accurate in both the EMR and the Echart.
• Serves as receptionist for office by answering telephones and giving out routine information properly and routing caller appropriately if necessary. This will be done tactfully, professionally and in a friendly manner.
• Receives and logs phone and written requests for information in the Meditech Release of Information application and responds according to established departmental policy and state/federal laws regarding release of information as well as ensuring proper authorization is received.
• Responds to Portal requests from our patients and assists with monitoring and follow-up with the portal access error reports.
• Treats all customers and co-workers in a caring, helpful and respectful manner, always displaying a willingness to assist. Exhibits exceptional customer service attributes with all interpersonal relationships.
• Interacts with medical staff effectively and professionally.
• Provides training for clinical students, as well as new employees.
• Provides coverage for other areas in the department and performs additional duties as requested.
• Displays adaptability in order to meet changing conditions in problem situations.
• Will be aware of and report any opportunities/instances of continuous process improvement.
  
  

Qualifications

QUALIFICATIONS:

Education: High school diploma or GED required.

Experience: Medical office experience or medical courses preferred, but not required.