Description
The SR Medical Records Tech will be responsible to review and analyze inpatient and ambulatory surgery medical records. Will review medical records for accuracy of pertinent documents, completeness of the physician signatures and other medical professional data entries. Will collaborate with the Medical Staff Office to report medical record deficiencies. Support the medical staff in the completion of the medical record and facilitate medical record availability.
Qualifications
Minimum Education
High School Diploma or GED (Required)
Minimum Work Experience
2 years Experience in processing and/or maintenance of medical records. (Required)
Required Skills/Knowledge
Strong knowledge of medical record content and identification of documents is required.
Must be reliable and trustworthy, maintaining strict confidentiality of sensitive information.
Demonstrates excellent communication skills and the ability to problem solve.
Presents self in a professional manner at all times.
Exhibits confidence and courtesy when addressing the medical staff.
Ability to meet quality and quantity productivity standards set by the medical records industry.
Demonstrates proficiency in all clerical functions of medical records management.
Demonstrated competency in computer skills and ability to operate in a Windows environment such as Microsoft Office and Word.
All job requirements listed indicate the minimum level of knowledge, skills, and abilities necessary to perform the job proficiently.
Functional Accountabilities
Medical Records Analysis
- Review discharged patient medical records for completeness and accuracy, based on hospital policy and accreditation and regulatory standards.
- Input incomplete data elements into delinquency database.
- Facilitate medical record availability for physician completion and retrieve medical records; contact physicians to inform them of the availability of the medical record for review and signature; re-review the medical record following physician review and signature activity.
- Monitor database to identify physicians with incomplete medical records; draft and send physician an incomplete medical record notification letter.
- File operative reports in the medical record.
- Perform clinical pertinence review of medical records per hospital policy and procedures; prepare medical record deficiency reports as needed by management.
Teamwork
- Collaborate with co-workers in the completion of daily assignments.
- Contribute to the overall team spirit of the HIM Department.
Education/Professional Development
- Seek educational opportunities related to medical records review and analysis.
- Participate in educational/in-service offering presented by the Human Resources Department.
Customer Service
- Participate in the CNMC's customer service education program.
- Extend assistance to all customers of the HIM Department.
Organizational Accountabilities
Organizational Commitment/Identification
- Partner in the mission and uphold the core principles of the organization.
- Committed to diversity and recognizes the value of cultural ethnic differences.
- Demonstrate personal and professional integrity.
- Maintain confidentiality at all times.
Customer Service
- Anticipate and respond to customer needs; follow up until needs are met.
Teamwork/Communication
- Demonstrate collaborative and respectful behavior.
- Partner with all team members to achieve goals.
- Receptive to others' ideas and opinions.
Performance Improvement/Problem-solving
- Contribute to a positive work environment.
- Demonstrate flexibility and willingness to change.
- Identify opportunities to improve clinical and administrative processes.
- Make appropriate decisions, using sound judgment.
Cost Management/Financial Responsibility
- Use resources efficiently.
- Search for less costly ways of doing things.
Safety
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