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|Department:||Health Information Man.-Coding & Data Integrity Services|
High School graduate or GED equivalent is required.
Secondary level courses in medical or business programs are preferred.
Successful completion of a Medical Terminology class will be required.
A customer relations seminar, i.e. dealing with difficult people will be required as course availability dictates.
External Applicants: A minimum of one year directly related experience in healthcare preferably working with medical records.
One year of experience in Medical Records at Munson Medical Center is required.
Must meet requirements of all levels of positions through level 3 and must have worked as a level 2 for at least six months.
Previous experience handling multiple telephone calls and filing systems is required.
Must come into Level 3 with knowledge of the seven (7) * applications listed below, and learn and remain proficient in all other applications relative to the department section you are applying for:
Chart tracking/deficiency system
Transcription and dictation system
Basic Access (census, ROI & data reporting)
STAR Account Inquiry
OTG Clinical Records
Information Release Systems
Electronic Birth Certificate
Ability to apply Joint Commission requirements, HCFA regulations, HIPAA regulations, Medical Staff Rules and Regulations, and department procedures when reviewing a medical record to identify deficiencies that could jeopardize hospital certification, legal and/or financial status.
Ability to work at a pace that achieves both a high quality and quantity of product
Ability to solve problems effectively and independently
Ability to effectively communicate and listen in a tactful and understanding manner
Ability to use effective written skills to document issues and/or resolutions
Ability to handle any combination of analytic functions
Ability to work independently
Ability to work in a team environment and toward team goals
Intermediate typing/keyboard/computer skills
Ability to type 40 words per minute
Organizational Relationships: Reports to a Manager of Medical Record Services.
Assists with training of new employees.
Provide shift-to-shift report for oncoming clerks.
Perform quality improvement activities as requested.
BIRTH CERTIFICATE (General Office):
Complete and submit a legal birth certificate for all newborns born at Munson Medical Center or Affiliate Hospitals and subsequently transferred to Munson. Communicate with physicians and staff regarding completion of the certificate as needed.
Interview parents for the completion of the legal birth certificate.
Coordinate and complete acknowledgement of paternity forms when necessary.
Communicate and educate parents of a newborn about legal requirements regarding birth certificate completion and/or acknowledgement of paternity forms completion.
Abstract medical record data when necessary for the completion of the certificate and acknowledgement of paternity papers.
Maintain the electronic birth certificate computer system by updating and adding to the physician tables.
Enter the information into the Electronic Birth Certificate computer system and generate the necessary forms.
Program and generate ad-hoc reports as requested from the Electronic Birth Certificate system.
Download and transfer information from the Electronic Birth Certificate system to the State Registry.
Communicates with the State of Michigan Department of Vital Statistics and appropriate County Clerk Offices for issue resolution.
Maintain a Notary status.
Update the Corporate Master Patient Index and Departmental Chart Tracking computerized systems to include the legal name of the child.
ARRANGEMENT/RECHECK/ANALYSIS/OTHER (General Office):
Applies knowledge of arrangement/analysis procedures for the following types of medical records:
Inpatient – Medical or Surgical
Inpatient – Psychiatric
Inpatient – Neonatal Intensive Care
Inpatient – Obstetric
Inpatient – Newborn
Emergency Room/Urgent Care
Outpatient Surgery and Procedures
Other Outpatient Records
Distinguishes reports/forms that are not necessary to maintain on the record and/or are duplicates and/or need to be forwarded to back to the originating department or the Medical Staff.
Generates chart tracking and deficiency system reports.
Applies the following to a medical record, regardless of patient type, to ensure that the record contains the necessary information to meet the regulatory requirements, financial justification and that it legally represents the care rendered to the patient:
Joint Commission and HCFA requirements.
Medical Staff Bylaws and Policies and Procedures.
Physician protocols for record completion.
Reviews medical records for record deficiencies based on the above rules and request completion by appropriate personnel/ medical staff member.
Enters record deficiencies into the computerized Chart Tracking and Deficiency system.
Reanalyzes records after being given to the appropriate person to ensure completion and update the computerized Chart Tracking and Deficiency system.
Validates physician dictation by monitoring the Transcription computer system for completion and update the computerized Chart Tracking and Deficiency system.
Communicates and/or explains to the Medical Staff the requirements necessitating the need for the missing documentation.
Routes records to appropriate locations based on protocols to ensure timely completion and coding/billing.
Communicates utilization of appropriate medical terminology and abbreviations.
Identifies Medical Staff members/signatures and their roles during a specified patient encounter.
Distributes facesheets of inpatient stays to appropriate Medical Staff members/offices.
Investigates all delayed or missing records with originating department.
Verification to ensure all outpatient records have been routed to the coding area for coding/billing in a timely manner using the Unbilled Account Report.
Identification of inaccurate patient registrations, resulting in accounts being held or not held appropriately for coding prior to billing. Correct the inaccurate registrations on the computerized Master Patient Index or communicate to the appropriate personnel for correction. Coordinate and/or communicate corrections with the coding area as necessary.
REQUESTS FOR RELEASE OF INFORMATION AND/OR RECORDS (General Office):
Release medical information to other healthcare institutions via the phone or fax.
Respond to calls from Insurance Companies for dates of service.
Route phone calls to correct Department of need, in and out of our Department.
Receive requests for records from departments treating patients within the house. Determine the appropriate record type/discharge date to meet the needs of the customer and create the record request slip for retrieval.
In the absence of a File Clerk, pull and deliver record for patient care.
REQUESTS FOR RELEASE OF INFORMATION AND/OR RECORDS (Release of Information Office):
Acts as receptionist for the entire Medical Record Department. Greet public in a prompt and friendly manner, answering their questions and/or directing them to those who can.
Answer telephone in a prompt and friendly manner, accurately recording, processing and routing messages.
Accurately respond to questions regarding the status of a request for information.
Assist customers with the completion of an information release authorization.
Release record copies directly to customers who have pre-arranged this service, including checking identification, obtaining authorization and transacting payment if necessary.
Assist Information Release Clerks by pulling records on demand, covering their phones during busy or short-staffed times and faxing record information to physician offices.
Process incoming outside and internal mail by printing the appropriate STAR MPI visit listing for each request and identifying potential duplicate or high priority requests. All mail must be processed within one working day of receipt.
Identify and print necessary documents from the electronic medical record for all types of information release requests.
Print results from computerized systems for selected types of requests (i.e. disability).
Obtain from clinical departments the records needed to fulfill a request. Monitor and follow-up on records not received within one week. Produce from computerized systems (i.e. OTG, MUSE), copies of records that are not stored by the Medical Record Department.
Coordinate the process for obtaining, copying and release of Physician Practice Network (PPN) records located at the facilities off-site storage.
Look up MPRO, DynkePro, KePro requests on STAR MPI, including visit dates and medical record number. Investigate charges on Medicaid outpatient requests to determine the needed record. Retrieve record, coordinate copying with vendor, maintain paperwork. On technical denials/higher weighted DRG review, copy chart and send.
Coordinate vendor copying of records for special projects (i.e. Blue Cross audits).
Retrieve record and copy needed documents or print from computer for Partial Hospitalization Program, Developmental Assessment Clinic, Hospice, Munson Oxygen Service, and send requested documentation by deadline.
Determine if release is required on non-physician dictation and forward to Information Release Clerk if release is required, or send the report if release is not required.
Enter request details in computerized information release software for selected types of requests or to assist Information Release Clerk when needed.
Identify/analyze documents need on Powerchart to fulfill information release requests.
MEDICAL INFORMATION ANALYSIS/STUDY (Med. Info. Analyst Office):
Coordinates activities and assembles necessary documentation for implementation and completion of outside audits, i.e. MPRO, Blue Cross, State of Michigan.
Analyzes, monitors and documents records using criteria indicators for Quality Management, peer review processes, Surgical Case Review Committee and Blood Utilization Review Committee.
Queries Powerchart to identify normal tissue values for Surgical Case Review Committee projects and requests.
Identifies possible maternal death cases for reporting to the State of Michigan.
Identifies cases required for review for Blood Utilization Review (BUR) Committee on a daily bases.
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