Essential Functions
- Works together with departmental and healthcare teams to complete assignments.
- Removes or arranges for removal of safety hazards from environment immediately to prevent potential safety hazards from occurring.
- Prioritizes and reprioritizes work based on the changing needs of the customers, in communication with the Director of Health Information Management.
- Keeps equipment in clean and working condition.
- Retrieves records for inter/intra department chart reviews as well as for all patient care units, if not previously scanned. Refers requestors internal to retrieve scanned documents via Meditech, PCI.
- Monitors requests for reviews of patient records and documentation so that records and documents are photocopied and submitted timely and accurately.
- Obtains and photocopies medical records for submission to third party payers within specific time frames of request.
- Retrieves medical records for the “correspondence company” to complete request for information within one week of receipt.
- Reviews all subpoenas and court orders for proper documentation and authorization to maintain patient confidentiality and legal rights to privacy.
- Verifies all authorizations for proper completion and signature prior to the release of medical records, in accordance with State and Federal Laws.
- Reviews and acts on pre and post payment reviews by third party payers to prevent payment denials due to the lack of patient record and/or documentation availability within specific time frames of request.
- Records all requests for Medical Records in the correspondence section of the Medical Records Module of Meditech.
- Maintains all microfiched medical records to assure that information is available when requested.
- Assures that by the fifth of each month all discharged patient records from the previous month are assembled and analyzed.
- Enters deficiencies into the Computerized Tracking System.
- Charts all miscellaneous reports, received after chart assembly, into the correct medical record within one week of receipt.
- Monitors physician compliance for chart completion on a daily basis.
- Maintains weekly suspensions of physicians to ensure compliance of Medical Staff by-laws with regards to incomplete medical records.
- Monitors, on a weekly basis, Performance Improvement efforts with regards to Medical Record Chart completion in accordance to JCAHO requirements.
- Reports monthly and quarterly Performance Improvement results to the Director of Health Information Management.
- Registers all patient deaths so that an accurate record of patient deaths is kept in the computerized system.
- Maintains a safe environment for patients by assuring that sharp objects, toxic substances and other objects potentially harmful to children are not accessible.
Assures that the environment of care or services is free of objects which may contribute to the likelihood of patient falls, slips or trips. - Is aware of the increased risk of falls, slips, and trips for elderly patients and visitors, and assures that the environment of care or services is free of objects and spills which may contribute to the likelihood of patient falls, slips, or trips.
- Is sensitive to the tendency of older patients to have hearing difficulties. Verifies that he or she is speaking with appropriate level of loudness so that the patient hears instructions, questions, and conversations, but that offense is not given to the patient as the result of the voice being excessively loud. Is able to differentiate problems with hearing versus problems with comprehension.
- Takes appropriate actions to assure physical security of children and complies with policies and procedures related to the prevention of neonate, infant and child abduction.
- Is aware of reduced endurance and strength present in many elderly, and provides accommodation for seating during extended interviews, discussions with secretaries, receptionists and other clerical personnel, or when the patient is waiting for transportation.
Statement of Other Duties
This document describes the major duties and responsibilities for this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described.
Functional Demands
Physical Requirement
Exerts up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. Frequently reaches (extending hands and arms in any direction), and handles (seizing, holding, grasping, turning, or working with hands).
Organizational Expectations
Behavioral Attributes
The following behavioral attributes are required: achievement motivation, concern for order; flexibility; initiative; self confidence; customer service oriented; interpersonal effectiveness; teamwork; analytical thinking and information seeking
