Medical Records Specialist

Job Details: Job Location: Caldwell Medical Center - PRINCETON, KY, Salary Range: Undisclosed, JOB TITLE:           Medical Record Specialist

DEPARTMENT: HIM

REPORTS TO:     Medical Records Supervisor

POSITION SUMMARY:

Is accountable for the delivery of consistently high quality effective and efficient entry of information into the computer system.
Functions under the supervision of Medical Records Supervisor.
Ensures appropriate organizational practices are in use.
Promotes good public relations through contacts with patients, practitioners, visitors, employees, peers and the public at large.
Maintains confidentiality of patient information.

POSITION ACCOUNTABILITIES

ESSENTIAL FUNCTIONS:

Collects emergency room, inpatient, outpatient, and swing bed records from their respective departments on a daily basis.
Assembles outpatient, emergency room, inpatient & swing bed records according to specific guidelines making sure appropriate test results are incorporated into the medical file.
Scans all outpatient, emergency room, inpatient and swing bed once sorted and assembled.
Ability to read and comprehend a large variety of memos, insurance requests, business letters, physician orders, nursing notations, diagnostic department reports and other information contained in patient’s records.
Answers the telephone and performs necessary tasks.
Routes & retrieves records needing signatures to clinic areas, the ER, and surgical departments.
Maintains a log of medical records requests to ensure timely completion, and ensures that all requests are processed within 30 days of receipt.
Utilizes the EMR Software program to locate patient information on the financial and the clinical side.
Handles requests for information following required guidelines.
Abides by changes within the department.
Obtains required signatures on forms according to established procedures and ensures information recorded is complete and accurate for processing of charges and billing.
Processes incoming and outgoing telephone calls efficiently, politely and quickly as possible while responding to inquires according to established policies for release of information.
Promotes a positive hospital image to patients and physicians by possessing a professional appearance and attitude.
Assists in maintaining established departmental policies and procedures, objectives, quality improvement program, safety and environmental standards. 
Assists in maintaining departmental reports and records as directed.
Assists in implementing department specific goals and objective in keeping with overall organizational goals and objectives.
Assists in maintaining adequate and effective communication between Medical Records/Business Office and ancillary departments for problem solving.
Interacts with others (on the phone or in person) in a positive, professional and appropriate manner.
Works cooperatively with others.  Has respect for and an understanding of the contributions of all team members.
Attends required meetings and participates in educational programs and in-service meetings.
Protects patient confidentiality by promoting appropriate staff communication practices.   
Works shifts as required.
Performs other related duties as assigned or requested.
Understands HIPPA and the guidelines that must be followed in order to effectively protect the patients privacy.

POSITION QUALIFICATIONS

MINIMUM EDUCATION

High School Graduate or GED

PREFERRED EDUCATION

High School Graduate or GED

MINIMUM EXPERIENCE

1 – 2 years with basic understanding of medical terminology

PREFERRED EXPERIENCE

3- 5 years with basic understanding of medical terminology

ENVIRONMENTAL CONDITIONS

Works in the Medical Records Office and works a schedule that the Health Information Manager agree upon.

WORKING CONDITIONS

Subject to varying and unpredictable situations. 
Subject to many interruptions. 
Frequent pressure due to multiple calls, inquiries, questions and requests. 
Performs both standardized and non-standardized duties that require independent judgment and initiative on an ongoing basis. 

EXPECTATIONS

Extensive knowledge of computer system and software.
Must be skillful in written and oral communication.
Must be able to compare similarities and differences between words and numbers. 
Demonstrates basic problem solving and time management skills. 
Must demonstrate the ability to interact with other personnel in a positive fashion. 
Must demonstrate the ability to work independently and to accept delegation of appropriate tasks from the Health Information Management Director. 
Must be able to write medical report vocabulary and business response language using proper formation, punctuation, spelling and grammar.

PHYSICAL DEMANDS

Work is mostly sedentary office environment.
Must be able to lift 25 pounds.*
Walk or stand without restrictions, able to stoop and pick up objects from the floor without restrictions.
Use of both hands and arms with a full range of motion.
No hearing loss greater than 40 decibels.

*Seek assistance if the weight requirement for the performance of a job or task requires greater than 25 lbs of effort/force

LANGUAGE SKILLS/READING SKILLS/HEARING

Ability to talk/converse with and understood by others.
Ability to read, analyze and interpret written information.
Ability to respond to common inquiries or complaints from customers
Ability to effectively present information to others (individually or in groups)
Ability to read dictionaries, thesaurus, technical journals and other related materials.

VISION

Far acuity: Ability to see clearly at 20 feet or more.
Must be able to visually identify, assess, and complete job-related tasks safely and accurately, with or without reasonable accommodation.  

SKILLS – ADMINISTRATIVE LISTING

 Answers and converses on the telephone.
Well organized and able to plan work well, managing time efficiently.
Be able to cope with last minute changes and difficult situations.

SKILLS – MACHINE LISTING

 Computer (Desktop)
Printers
Copy Machine
Fax Machine
Telephones – Desk
3-M en-coder

Qualifications: POSITION QUALIFICATIONS

MINIMUM EDUCATION

High School Graduate or GED

PREFERRED EDUCATION

High School Graduate or GED

MINIMUM EXPERIENCE

1 – 2 years with basic understanding of medical terminology

PREFERRED EXPERIENCE

3- 5 years with basic understanding of medical terminology