Medical Records Specialist

JOB TITLE: Medical Records Specialist FLSA STATUS: Non-Exempt DEPARTMENT: Medical Services SUPERVISED BY: Medical Records Supervisor

I. POSITION FUNCTION SUMMARY

Under the general direction of the Health Services Manager and Medical Records Supervisor, the Medical Records Specialist has general responsibility for maintaining electronic patient files, responding to and fulfilling requests for medical records and assisting in the collection of data.

II. ESSENTIAL DUTIES AND RESPONSIBILITIES

This position may have various work assignments within HICHC. This description is intended to be generic in nature, and as such it does not detail all duties and responsibilities of the particular job assignment. Various duties, responsibilities and accountabilities may be assigned to an incumbent in this position depending on the specific job assignment, and may include but not be limited to the following:

• Maintains electronic patient files and scans all patient data upon receipt.
• Responds to requests for medical records; processes letters and reports; answers and directs telephone calls.
• Retrieves and distributes lab, radiology and specialist reports to physicians requests information from various departments; responds to correspondence requests.
• Pulls records and documents for billing and/or legal services; sends and receives information via email, facsimile machine, drives, certified mail delivery, CD and Thumb Drive.
• Demonstrates appropriate utilization of medical record to document care within scope of job duties.
• Actively participates in quality improvement and risk management programs.
• Participates as an active team member on the patient care team.
• Participates in continuing education activities.
• Documents appropriately in the patient medical record.
• Demonstrates positive interpersonal relations in dealing with physicians, patients, patient families, visitors, co-workers, in a professional and confidential manner.
• Embraces the philosophy of continuous quality improvement.
• Maintains a safe, clean, and confidential working environment consistent with OSHA, HIPAA, and HHC standards.
• Manages changes in work demand during work-day.
• Ensures patient/family satisfaction with medical record processes.
• Keeps supervisor informed of problems or issues; monitors supplies needed; performs other duties as assigned.

This individual must be able to effectively communicate both in written and oral form. This person must be capable of prioritizing and organizing tasks related to patient care. The medical records specialist is expected to support the Health Center's mission and adhere to Health Center policies and procedures, as well as applicable state and federal regulations. He/she is expected to demonstrate superior organization, ability to multi-task, have effective interpersonal skills and be an active part of the patient care team

III. POSITION SPECIFICATIONS

Requirements of Position

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.

Education and Experience

• High School graduate or GED certificate.
• One year of related clinical office experience and/or training is required; OR any equivalent combination of experience, training and/or education.
• At least one year of medical records experience.

Knowledge, Skills and Abilities

This position requires a basic knowledge of general office procedures to include filing, copying, and faxing.

• Ability to use a computer to enter patient data and retrieve information.
• Ability to work on multiple tasks within established deadlines.
• Ability to work under the direction of a supervisor and follow instructions.
• Ability to take the initiative to resolve patient concerns and problems.
• Knowledge of patient chart documentation.
• Ability to communicate effectively in written and oral form with a diverse population.
• Demonstrate above average organizational capabilities.
• Demonstrate above average teamwork capabilities.
• Ability to multitask in a supportive patient care role to a diverse population.

Language Skills

• Ability to read and interpret documents such as government regulations and guidelines, patient records, operating and maintenance instructions, procedure manuals, etc.
• Ability to write at a minimal level of competence, including internal reports and memoranda.
• Ability to communicate with diverse groups of people to include staff and providers and patients.
• Ability to communicate effectively with patients and their families to make their visit a pleasant experience.
• Sensitivity to the multicultural nature of the service area population and may be required to assist patients using interpreter services.

Personal Characteristics

Personal characteristics include: a team player, high integrity, communication and customer relations skills, regular work attendance, courteous and friendly, able to work well with diverse groups of people, gain and maintain respect of others, accept HICHC mission and values.

Confidential and Sensitive Information

Because the employee has access to personal and professional data regarding individual employees and their families, personal data regarding individual patients and the families, and/or sensitive company financial data, an essential job result is the maintenance of a high level of confidentiality of the information processed by the employee. Violation of this confidence may result in disciplinary action, up to and including termination of employment.

IV. PHYSICAL CHARACTERISTICS/WORKING CONDITIONS

General Remarks: The work environments described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential tasks and functions.

Environment: Noise level in the work environment is low to moderate. There are no known environmental hazards on the premises. Work environment is often stressful and may be subject to frequent interruptions. Work is in the office. Occasional travelling off site may be required. Incumbent may be exposed to patient’s conditions and some unpleasant sights, smells and contagious diseases including virus, disease and infection from patients and specimens in working environment. All employees are offered the opportunity to receive the Hepatitis B vaccination series.

Equipment Use: Telephone system and office equipment including but not limited to computer, printer, facsimile machine, copier and general office supplies.

Work Hours: Incumbent will be scheduled based on operational need.

Mental Demands: Duties require attention to detail, alertness, problem solving, tolerance to stress and exercising sound judgement. Duties require high tolerance and adequate coping skills for dealing with loss, grief and bereavement. Good stress reduction and management skills are essential.

V. REMARKS

The foregoing position description is not all-inclusive of the duties that may be assigned to the employee. To ensure maximum flexibility and efficiency and to encourage cross training, employees will be assigned additional duties as deemed necessary or desirable by HICHC.