Position located at Lakeside Medical Center in Belle Glade, FL.
Lakeside Medical Center is a Joint Commission-accredited, 70-bed acute care facility located in the heart of the Glades communities in western Palm Beach County. Lakeside Medical Center, which is owned and operated by the Health Care District of Palm Beach County, is committed to providing quality, compassionate care. In 2012 Lakeside Medical Center received national recognition for quality measures and patient satisfaction. For more information, visit www.lakesidemedical.org or call 561-996-6571.
General Statement of Job
This position is responsible for processing admissions on all inpatients, observation patients, and same-day surgery patients. The employee compiles, processes and maintains medical records of hospital patients in accordance with established hospital policies, procedures, as well as state and federal regulatory and compliance regulations and standards.
Specific Duties and Responsibilities
Processes patient admission and discharge documents in accordance with applicable regulations.
Enters patient data such as demographic information, medical history, diagnoses, diagnostic procedures and treatment into the computer system.
Assigns the patients to the appropriate diagnosis-related groups (DRGs) in the computer.
Maintains the data integrity in the Master Patient Index (MPI) of the Integrated Network System.
Answers all calls coming into the office. Routes communications to appropriate personnel as needed.
Delivers patient medical record charts to the units for re-admissions.
Pulls and re-files charts for review and for any patient, physician or medical personnel that may need them while maintaining strict adherence to patient confidentiality regulations and standards.
Copies medical record charts for the patients that transfer out of the facility and other appropriate requests.
Assembles, abstracts, and spindles discharged patient charts.
Requests and re-sends charts to and from the hospital’s medical record storage company as required.
Obtains and reviews the patient discharge lists for inpatients, observation, ambulatory surgeries, and other admissions.
Prepares birth certificates according to guidelines published by HRS and the State of Florida.
Faxes birth log report on a weekly basis to the Department of Health.
Ensures concurrent reviews are conducted on all patients in-house and verifies that their medical history and physical information is in their medical record.
Follows up with the ER daily to maintain that all records are sent to the Medical Records Department within three (3) days of discharge.
Assists the Coder to ensure that the bill monitor report is current with no outstanding records to be coded.
Reviews all patients in-house medical records, verifying that verbal orders are signed within forty-eight (48) hours of being ordered/written and follows up with physicians as appropriate.
Picks up discharged charts daily, assists with pulling of records, birth registers, filing of records, and spindling of records.
Prepares and scans all Emergency Room records in a timely manner.
Handles all requests for records for discharged patients, within the appropriate timeline as per state law.
Logs all medical record requests into the department’s log system.
Analyzes discharged charts for verification of completion and compliance as per JCAHO and state guidelines. Resolves any identified omissions and/or discrepancies.
Communicates with HIM Supervisor regarding warning letters and suspension notifications for physicians.
Protects the security of the patients’ medical records to ensure that confidentiality is maintained. Maintains patient confidentiality at all times according to the hospital’s established policies and procedures.
Adheres and follows all hospital and departmental policies and procedures.
Applies the hospital’s principles of safety in all work practices. Reports any identified safety risks or incidents per the hospital’s policies and procedures.
Maintains a neat, orderly and safe work area.
Follows all infection control and employee health policies and procedures at all times.
Emergency duty may be required of the incumbent that includes working in special needs or Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.
This job description reflects the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a complete description of all the work requirements and expectations that may be inherent in the position. The omission of specific statements of duties does not exclude them from the position. Management of the Health Care District of Palm Beach County reserves the right to assign duties not listed herein as necessary to accomplish the goals of the organization.
High School Diploma or GED required.
Six (6) months to one (1) year experience in hospital or medical records preferred. Strong computer typing skills are essential.
The Health Care District is an Equal Employment Opportunity Employer and maintains a Drug Free Workplace. Qualified individuals with disabilities who require an accommodation to participate in the application process should contact Human Resources. Veterans preferred.
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