Medical Records Technician II- CMHHIP

Department Information

Description of Job

• Files all records by terminal digit filing system.
• Check charts out to doctors, and other clinicians on an as needed basis.
• Completes the paper Medical Records Out guide and Request card.
• Checks the charts out in the chart tracking database and files the paper Medical Records Out guide and Request card in the tickler file.
• Checks the tickler file daily and calls for charts that are due back in the file room.
• Provides prompt friendly service to internal and external customers in a professional manner in the reception area of the department.
• Treats customers with respect and directs customers to appropriate locations if the customer needs assistance.
• Manages the Medical Records File room by moving records on an ongoing basis to ensure plenty of room to retrieve and file records.
• Pulls death charts and files them on the death shelf.
• Boxes death charts as needed and takes them to storage.
• Heads up and files any and all loose papers that come to Medical Records, in the proper charts, to ensure complete records.
• Must be familiar with BEHR, the electronic Health record, specifically Power Chart; Access HIM, and Revenue Cycle.
• Is responsible for verifying what documents should be scanned and what documents should not be scanned. Is responsible for verifying the identifying information on documents to be scanned.
• Is responsible for scanning information in the correct patient, correct episode, and correct folder. Maintains Standard Operating Procedure document for scanning documents. Scans discharge signature pages, advance directives, outside laboratory and pathology, death certificates, verbal authorization (100C), master treatment plans, and other documents authorized for scanning.
• Retrieves paper charts from storage, if applicable, for readmissions and places them back in the file room.
• Responsibility to answer incoming phone calls.
• Independently releases patient information for continuity of care to requesters per required HIPAA Federal Regulations.
• Pre-release packets (Social Security benefits of all types), Medicaid benefits, etc., are sent to the requestor when processed.

• Understand current HIPAA regulations.
• Work with CDHS HIPAA privacy & Security Officer to assist in modifying policies and procedures to incorporate OCR & CDHS HIPAA regulations.
• Review policies every two years or after any change in HIPAA regulations.
• Complete initial audit of all buildings using the Environment of Care Audit Tool.
• Assess recommendation for HIPAA compliance, if identified.
• Work with CDHS HIPAA Privacy & Security officers for expertise & funding if required.
• Works with Staff Education to assign HIPAA training as needed.
• Contact employee supervisor to require employee follow up for identified HIPAA violations to assure HIPAA training was completed...
• Complete Annual Risk Assessment.
• Review new HIPAA regulations and modify policy/procedure/audit standards in conjunction with HIPAA officers.
• Prepare a monthly HIPAA reminder to CMHHIP campus to improve HIPAA compliance, this should be specific for each Division based on needs and/or breaches.
• Utilize email reminders, staff meetings, and newsletters.
• Report all HIPAA violations and breaches to HIPAA Officer and Division Management.
• Complete HIPAA risk Assessment form.
• Use the Compliance Tracking Report.
• Work with HIPAA Officer and management to mitigate Security and Privacy breaches and/or incidents.
• Report IT security incidents to the help desk. (Examples include: stolen laptops, screensaver not turning on, hacking, spam, and access issues etc.) Once the OIT help desk is notified, by regulation, CDHS has 30 days to mitigate and/or remediate the situation.
• Interview staff related to HIPAA violations
• Determine if PHI was compromised
• Notify clients of any potential privacy or security risks to their data. Document the entire incident, use form.
• Document CDHS good faith effort to comply within 30 days, state the current and future remediating plan so the incident doesn’t repeat itself.
• Participate on the CDHS HIPAA Steering Committee meetings.
• Continue to keep the HIPAA on-line training presentation up-to-date.
• Provide periodic HIPAA training to targeted audiences,
• Monitor the encryption of mobile device usage in your division.
• Facilitate the appropriate use of Business Associate Agreements, MOUs & MOAs in your division.
• Contact the CDHS HIPAA Privacy & Security officer for assistance.
• Other duties to ensure compliance with updated HIPAA regulations.

• Independently releases patient information to requesters per required HIPAA Federal Regulations. Determines what type of authorization is required per HIPAA Federal Regulations. Allows inspection of the record and provides copies. Releases information to requesters who are authorized by law to receive information with or without patients consent (Medicare, Medicaid, Attorneys, Social Security and Courts). Maintains release of information log, and documents all information released into Release of Information database. Records must be copied and released within 10 days of receiving the records request per CDPHE Regulations.
• Determines what medical record exists by matching the information provided by the requester with the computerized database, microfiche, Microfilm logs, and medical records. Determine costs of copies of copied patient information by counting medical record copies and sending billing statements to requesters. Update release of information log when payments are received and forward payments to the General Accounting Department. Locates and retrieves records from the file room, store room, or chart room and files the record back in the appropriate area after placing authorization.
• Releases confidential information to authorized requesters, by telephone or in person. Forwards patient phone calls or refers requesters to proper individuals if more information is needed. Treats customers with respect and directs customers to appropriate locations if the customer needs assistance. Provides prompt friendly service to internal and external customers in a professional manner. Interacts professionally with people, especially in difficult circumstances. Also, communicates and interacts with peers and colleagues in a positive manner.

• Completes audits using Google sheets audit form for ECT, admissions, concurrent, outpatient, discharges, and deaths for compliance with all hospital policies, procedures and regulatory agency requirements; the results populate in a Google sheet.
• Enters deficiencies in BEHR for Providers.
• Deficiencies found during the chart audit process are placed in the Outstanding Errors spreadsheet.
• Responsible for running the “Saved not Signed” report and notifying staff of documents needing to be signed.
• Responsible for tracking Initial Plans of Care and subsequent Treatment Plan Reviews according to CMS requirements.
• Keep a record of due dates for RN annual assessments, and Social Work and Psychiatric biannual assessments, and send reminders to staff. Deficiencies found during the chart audit process are placed in the Outstanding Errors spreadsheet.
• Send “Saved, not Signed” and Therapeutic documentation deficiencies to each individual monthly.
• Requests death certificates for deceased patients.

• Abstract data from charts to be reported to the Joint Commission, CMS, and ORYX.
• The Hospital-Based Inpatient Psychiatric Services (HBIPS) core measure initiative is a major national leadership effort to improve quality, safety, and performance of hospital-based inpatient psychiatric services through the collaboration of hospitals, physicians, and consumers. Core measures for hospital- based inpatient psychiatric services (HBIPS) are one of several sets of core measures the hospital tracks and enters into the BEHR Database.
• Assures the accuracy of core measures for admission from the BH intake in BEHR.
• The discharge measures consist of Alcohol abuse, tobacco, immunizations and metabolic screening. Assures the Measures for discharge from the discharge chart consist of Continued Care Plan-Reason for Hospitalization, Discharge Diagnosis, Medications, Next Level of Care Recommendations, if there is an aftercare appointment date, are there scheduled antipsychotics at Discharge, is there a referral for alcohol and drug treatment if they have a diagnosis or prescription for alcohol and drug treatment, is the information transmitted to the Health Care Professional and Metabolic screening form.
• There are approximately 30 discharges per month that need to be entered before Denver files the report. Verifies all the admissions and discharges from the admission and discharge list for the month are entered into BEHR.
• Scan SP1’s, and signature pages. Maintains the Standard Operating Procedure for abstracting and scanning

• This position requests and obtains all authorizations for third party payer insurance reimbursement, based upon medical necessity. Third party payers include, but are not limited to Medicare, Medicaid, Tri-Care, and private insurance carriers. Duties include:
• Request authorizations each day by referring to the daily admissions list, and the third party payer form, and initiate the authorization process.
• Understands which patients are eligible for third party payer reimbursement, and all processes related to obtaining authorizations.
• Maintains a current contact list for each insurance carrier, and all departments/persons involved in utilization review.
• Submits appropriate medical record documentation to third party payers upon request and at established intervals.
• Performs appropriate follow-up for lack of response from the third party payers or others involved in the utilization review process.
• Independently problem-solves issues in the authorization request process, but understands when additional review is required.
• Maintains a tracking tool for authorization requests to minimize incidence of missing information or delay in submission of required documentation, or renewal of authorizations.
• Reports current authorization information or concerns to the Utilization Review Manager, weekly, at a minimum.
• Schedules clinical consultation meetings for provider/clinical team member with the insurance representative as needed.

• Responsibility to perform assigned tasks and duties within the scope of practice for this position that do not fall within the realm of duty statements A-F to meet the vision and mission of the agency and/or the department.

Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights

Minimum Qualifications:

Two years (2) of Medical Records Experience in a hospital setting or previous medical records technician experience.

Certification related to the work assigned to position will substitute for the required
experience. This includes Medical Coding and Billing Certification.

Substitutions:

Appropriate education will substitute for the required experience on a year-for-year
basis. This includes RHIT and RHIA

Conditions of Employment:

• CDHS employees (all Direct contact with vulnerable persons): CBI name check and fingerprint check, ICON Colorado court database, Medicare fraud database, Reference Checks, Professional License verification (licensure requirements), Drug Screen, PREA (Division of Youth Services), Trails check (direct contact with children), CAPS (direct contact with adults – Mental Health Institutes, Regional Centers, Veterans Community Living Centers).
• Shall not initiate or engage in sexual, social, personal or financial relationships with patients either during or any time after hospitalization, even if the patient requests or initiates such a relationship. All relationships with current or former patients must be disclosed on your application;
• Successfully pass all modules of the CMHHIP New Employee Orientation core curriculum to include English reading comprehension, relevant competency assessments and written/practical exams;
• Ability to read and comprehend the English language; effectively and fluently communicates in English, both verbally and in writing;
• 2-step TB (tuberculosis) screening is required of all new employees upon hire;
• Annual influenza vaccination required.
• Former State employees who were disciplinarily terminated or resigned in lieu of termination must disclose the information on the application and provide an explanation why the prior termination or resignation should not disqualify the applicant from the current position. Absent extraordinary circumstances, prior disciplinary termination or resignation in lieu of termination will disqualify the applicant from future State employment with CDHS

• If you receive notice that you have been eliminated from consideration for this position, you may file an appeal with the State Personnel Board or request a review by the State Personnel Director.
• An appeal or review must be submitted on the official appeal form, signed by you or your representative. This form must be delivered to the State Personnel Board by email (dpa_state.personnelboard@state.co.us), postmarked in US Mail or hand delivered (1525 Sherman Street, 4th Floor, Denver CO 80203), or faxed (303.866.5038) within ten (10) calendar days from your receipt of notice or acknowledgement of the department’s action.
• For more information about the appeals process, the official appeal form, and how to deliver it to the State Personnel Board; go to spb.colorado.gov; contact the State Personnel Board for assistance at (303) 866-3300; or refer to 4 Colorado Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, at spb.colorado.gov under Rules.

Supplemental Information

• Strong, secure, yet flexible retirement benefits including a PERA Defined Benefit Plan or PERA Defined Contribution Plan www.copera.org plus 401(k) and 457 plans
• Medical and dental health plans
• Employer supplemented Health Savings Account
• Paid life insurance
• Short- and long-term disability coverage
• 11 paid holidays per year plus vacation and sick leave
• BenefitHub state employee discount program
• Employee Wellness program MotivateMe
• Excellent work-life programs, such as flexible schedules, training and more

• Remote work arrangements for eligible positions

• 
  Some positions may qualify for the Public Service Loan Forgiveness Program. For more

We believe in a people-first approach: To serve the people of Colorado, we develop a culture and work environment that creates an energized, inspired, and healthy team capable of giving their best to Coloradans.

Balance creates quality of life: We want our team to be resilient through a supportive workplace that values flexibility, health and wellness, and employee engagement.

We hold ourselves accountable: We take responsibility through our actions, programs, and results for the state of health and human services in Colorado.

Transparency matters: We are open and honest with employees, our partners, the Coloradans we serve, and the public.

We are ethical: We abide by what is best for those we serve by doing what is right, not what is easy.

Collaboration helps us rise together: We work together with all partners, employees, and clients to achieve the best outcomes for Coloradans.

We are committed to increasing the diversity of our staff and providing culturally responsive programs and services. Therefore, we encourage responses from people of diverse backgrounds and abilities.

ADAA Accommodations: CDHS is committed to the full inclusion of all qualified individuals. As part of this commitment, our agency will assist individuals who have a disability with any reasonable accommodation requests related to employment, including completing the application process, interviewing, completing any pre-employment testing, participating in the employee selection process, and/or to perform essential job functions where the requested accommodation does not impose an undue hardship. If you have a disability and require reasonable accommodation to ensure you have a positive experience applying or interviewing for this position, please direct your inquiries to our ADAA Coordinator, Nancy Schmelzer, at cdhs_ada@state.co.us or call 1-800-929-0791.