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Medical Records Specialist
Department: Medical Records-Coding
Schedule: Full-Time
Shift: Day shift
Hours: 40 hrs
Salary: $12.73-$17.22
Job Details:

The schedule for this position is Monday through Friday 8:00 a.m.-4:30 p.m.
REQUIREMENTS – Must meet Clerical Levels 1-4 Requirements and Attributes

Education:

High School graduate or GED equivalent is required.

Associate’s degree preferred.  In lieu of associate degree, consideration will be given to individuals with recent relevant experience and education.

Successful completion of a Medical Terminology class is required.

Requires customer relations seminar, i.e. dealing with difficult people.  (Required within 3 months).

Previous Experience:

Two years in medical records required at Munson Medical Center (at a level 3)

Previous experience handling multiple telephone calls and filing systems is required.

Must come into Level 4 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:

Kronos

GroupWise

Microsoft Office – Advanced

Basic Access (census, ROI & data reporting)

Chart tracking/deficiency system

Transcription and dictation system

Powerchart

STAR MPI

STAR Account Inquiry

OTG Clinical Records

Scan Trax

Information Release System

Electronic Birth Certificate

Capabilities:

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 use effective written skills to document issues and/or resolutions.

Ability to effectively communicate and listen in a tactful and understanding manner

Advanced typing/keyboard/computer skills:

                Ability to type 40 words per minute.

                Ability to handle any combination of analytic functions.             

                Ability to work without supervision and independently

                Ability to work as a team leader and toward team goals

No managerial responsibilities, but has the ability to act on behalf of the coordinator in his/her absence.

Assists with the training/mentoring of new employees.

Assists with the completion of the new hires orientation.

Organizational Relationships:  Reports to Manager of Medical Record Services.

SPECIFIC DUTIES:

Completion of the physician notification/suspension process (i.e. daily monitoring of physician activity, physician notification, suspension of physician and notification to applicable areas in accordance with Medical Staff policies and procedures).

Physician orientation

All recheck of charts

Birth Certificate processing

PEERS reporting

Rubber stamp issue reporting

Office vacation request, including yearly calendars.  Scheduling of monthly file clerk duties

Quality checks of all scanned documents

Maintains physician auto pulls list.

Powerchart training of all new employees

Analysis of ED, OP and/or IP charts when needed

Enters vacation/sick time in Kronos in Coordinator’s absence.

Back-up for Transcription Specialist in their absence

Employee will be the back up to the MPI Data Integrity Coordinator/MR Transcription Coordinator/Office Coordinator in his/her absence or when assigned as needed.

Must be able to educate and apply Joint Commission requirements, HCFA 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.

Must be able to recognize potential problems, using investigative skills, validate the problem and report it to the appropriate person or institute corrective action as appropriate.

Must be able to prioritize work and assign work to Medical Record Clerks and File Clerks to meet conditions and/or customer needs.

Perform quality improvement audits as requested.

MASTER PATIENT INDEX VERIFICATION (MPI Data Integrity)

Perform data integrity monitoring to insure that the computerized record is accurate, complete and timely and meets the clinical, legal and financial requirements for a medical record.

Analyze reports/work queue to identify potential duplicate cases on the computerized Corporate and Facility Master Patient Index and report such cases to appropriate departmental staff for investigation and correction as necessary.

Investigate potential duplicate cases by combination of the following methods:

                Review of the patient demographical information.

                Comparison of patient signatures contained on various previously signed consents.

Comparison of the medical history, disease process and medications contained in previous and current medical records.

                Communication with the patient.

Correction of the computerized Corporate and Facility Master Patient Index and the Departmental Chart Tracking systems.

Correction of the medical record and consolidation of the records to the appropriate filing area.

Coordinate with ancillary departments, the merging of all duplicate patients within the computerized clinical record and associated feeder systems; including Medical Record Services systems.  Perform merges as appropriate.

Process alias patient visits; correcting the Corporate and Facility Master Patient Index, Departmental Chart Tracking computerized systems and the actual patient record.

Report the status of the accuracy of the MPI and possible error trends to the appropriate personnel.

UNBILLED ACCOUNT/ RECORD PROCESSING (General Office Area)

Correct computerized Chart Tracking and Deficiency system as appropriate.

Ensure all records have been coded prior to permanent filing or transportation to hospital for permanent filing.

Responsible for applicable e-Signature HIM reports.

CENSUS & STATISTICS (General Office Area)

Daily computer census update.

Perform retrospective census changes.

TRANSCRIPTION REPORT PROCESSING (Transcription Area)

Transcription System

                Distribution of report copies for medical staff and other health care providers.

                Searching by unit number, name or directory to locate information.

Process outside services work, which includes attaching the correct demographics and finalizing the report.  This work is not accessible for billing, continued patient care or record completion processes until it is processed.

                Prioritize the processing of reports to meet the needs of the customers.

                Extensive knowledge of batch printing.   

                Indepth knowledge of the Physician Profile and its content.

                Knowledge of which physicians are utilizing the faxing features.

                Printing reports via the computer system to nursing units that have network printers.

                Utilizing the Corporate Master Patient Index when needed.

                Communicate and support the Medical Transcription staff.

Knowledge of the operation and use of the transcription system and for adhering to specified policies and procedures for the system.

Ability to edit reports when requested by physicians and Medical Records.  Correcting signature blocks, misspelled words, wrong physicians in the “cc” field, and changing the document per physician request.

                Familiarization with macro’s that operate special keyboard functions.

Mail Processing:                   Responsible for mailing reports and suspension letters to physicians.  

Knowledge of physician mailing preferences and processing the copies per departmental protocols.

Maintaining the address labels which entails new additions and change of addresses.

                                                Looking up addresses of physician not in our local area.

Knowledge of which reports can or cannot be mailed out from a legal/patient confidentiality perspective.

Requests for Reprints:          Reprints to physician offices via the faxing module through the computerized Transcription System.

                                                Assist MR Transcription Coordinator with reprints for quality checks.

Purchasing/Ordering:          Responsible for utilizing the purchasing card to order special transcription items.

                                                Responsible for maintaining paper and toner supplies.

Phone:                                   Answer phone calls for the Transcription Area in a friendly manner.

                                                Take accurate messages and distribute them to the appropriate personnel.

Central Dictation System:    Knowledge of the operation and use of the Central Dictation System and adhering to the specified policies and procedures for the system.

Ability to receive and communicate issues with the system, such as down time, to the appropriate personnel and the medical staff.

Knowledge of and the ability to communicate how to use the Listen Access option for radiology and transcribed reports.

Ability to run turnaround reports for management to determine what work will be completed in-house or by an outside service.

Ability to problem shoot problems and to communicate unresolved issues to management and/or the lead.

Maintaining logs from the transcription system that are batch printed and out sourced work in appropriate order.

Surveying the medical staff to determine if they would be willing to receive reports in their office via the faxing option.  This includes mailing out surveys, answering questions about the equipment requirements of the system.

Reference Books:                  Putting together and maintaining reference books for the Transcriptionists.

                                                Using reference materials to assist home Transcriptionists with questions.

Report registration errors to Patient Access Services for correction of the Corporate Master Patient Index.

Responsible for communicating and logging computer, server, network, transcription and dictation system related problems with the Information Systems Help Desk.

Computer Systems used:     Transcription System

                                                Master Patient Index

                                                Dictation System

Responsible for applicable e-Signature HIM reports

UCN chart processing

RELEASE OF INFORMATION (ROI Dept.)

Respond to requests for medical record information in accordance with federal and state regulations and hospital policies and procedures.

Interpret multiple patient index sources (e.g. STAR, SUNQUEST, TCCH Prodigy, ScanTrax, Cerner PowerChart, microfilmed card, admission logs and daily census sheets) to obtain/locate records/information requested.

Obtain records from other Munson departments and affiliate storage sites to fulfill requests for Munson and PPN records.

Act immediately to fulfill medical emergency requests for records.

Enter and update request information on Information Release software.

Coordinate and gather specimens, films or tracings when needed in conjunction with requests for records.

Prepare records for several types of subpoenas, search warrants and Attorney General requests.

Produce records to fulfill requests either by copying the paper record or printing from Cerner MRP or PowerChart on line documentation.

Communicate and problem-solve issues with requesters (i.e. law enforcement, attorneys, patients).

Utilize the following computerized systems when necessary, to gather/produce records:  SUNQUEST, STAR Radiology, Medical Record chart management system, WINFRAME Resource Server (itemized bills), STAR Accounting and Dolbey Transcription, OTG Viewer, Rehab Services Database, and Disclosures Log (blood alcohol).

Implement complex search procedure to locate records stored on film or fiche spanning a 70-year period.

Prepare invoices for copies of medical record information.

Testify in court, if necessary, regarding medical records delivered to the court.

Respond to customer complaints, if any.  Work with the Patient Liaison to resolve issues.

Assist the Risk Management Director in preparing records for pending litigation and depositions.

Prepare record copies needed for Quality Management certification cases.

Prioritize assignments daily in consideration of request deadlines and Departmental needs.

Coordinate activities of clerical support staff that are members of the Information Release team.

Coordinate activities and related procedures of contracted record copy service staff.

Arrange on-site medical record reviews with authorized requesters, with prior management approval.

Act as a resource for MHC affiliates for release of information questions.

Produce monthly productivity reports.

Maintain/coordinate maintenance of copy machine, microfilm reader printer and fax machine.

Ensure appropriate authorization is received for PPN records, prepare invoice notices and resolve customer concerns as needed.

               

 

 

 

   
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