Compiles and maintains medical records of patients of health care delivery system to document patient condition and treatment.
Position requires bending at waist, standing and sitting in order to retrieve, file, compile, copy and mail records/reports. Must have knowledge of medical terminology and good communication skills to deal with the public and hospital physicians/staff. Must demonstrate essential computer skills to perform required duties/functions of the position.
DUTIES AND RESPONSIBILITIES:
1. Analyzes and reviews medical records for completeness and accuracy of documentation according to specified standards.
2. Abstracts clinical data such as diseases, operations, procedures and therapies on medical records according to specified standards.
3. Assigns other data as necessary.
4. Monitors completion of medical records in accordance with time standards.
5. Audits incomplete records and prepares reports on delinquencies.
6. Confers with doctors, nurses and other health care personnel to assure complete, current and accurate medical records.
7. Compiles, maintains and reviews logs, reports and statistical records, along with researching records to locate health data as requested.
8. Maintains and utilizes storage and retrieval systems.
9. Operates computer to retrieve health information.
10. Assists in identification of medical records needed for research or review by authorized personnel.
11. Assists the Revenue Cycle Director in special studies or research as needed.
12. Processes and files transcription.
13. Prepares input for computerized medical information systems and for processing vital statistics, insurance and other forms and documents.
SKILLS AND ABILITIES REQUIRED:
1. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
2. Correct use of the English language.
3. Ability to perform routine mathematical calculations.
4. Necessary reasoning skills.
5. Ability to efficiently use a computer, printer, copies to perform job duties.
EDUCATION AND EXPERIENCE REQUIRED:
1. High School Graduate or equivalency.
2. Prefer minimum one (1) year experience in Health Information Management Department.
3. Prefer college courses relating to Health Information Management.
4. Thorough understanding of HIPAA.