JOB DESCRIPTION:
Abstracts information from the record on each inpatient, outpatient and Emergency Department visit into the computerized medical record data base. Ensures accuracy and integrity of medical record abstract data prior to billing interface. Maintains statistical information for all hospital departments. Coordinates the flow of information between the Performance Improvement Department and the Health Information Management Department.
DUTIES AND RESPONSIBILITIES:
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Maintains hospital daily census.
- Maintains credentialing files for all providers; updating expiring certificates, licenses, etc.
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Responsible for maintaining supplies for the department.
- Maintains death log.
- Abstracts ongoing blood audit medical records for Pathology and Performance Improvement departments, meeting established deadlines.
- Prepares medical records for performance improvement studies and service committees, meeting established deadlines.
- Assures that medical records are abstracted within three (3) days of patient’s discharge.
- Pulls requested medical records within time specified. Abstracts information from medical records by keying the information into the computer census abstract system, maintaining a 100% accuracy rate.
- Assumes responsibility for cross-checking quality, accuracy and completeness of abstracts.
- Assists in answering the telephones and taking accurate messages.
- Assists in retrieving medical records for physician completion, when necessary.
- Performs performance improvement functions through data collection and documentation review.
- Is familiar with pediatric and SNF medical record requirements.
- Maintains hospital requirements, policies and standards on confidentiality.
- Copy, record and send medical records as requested by insurance companies, government agencies, medical facilities and attorneys.
- Scans documents correctly to the electronic health record system
- Supports and maintains a culture of safety and quality.
- Maintains a good working relationship within the department and other departments.
- Adheres to dress code, appearance is neat and clean.
- Completes annual education requirements.
- Maintains regulatory requirements, including all federal, state, local regulations and accrediting organization standards.
- Maintains patient confidentiality at all times.
- Reports to work on time and as scheduled, completes work within designated time.
- Wears identification while on duty, uses computerized punch time system correctly.
- Completes in-services and returns in a timely fashion.
- Attends annual review and department in-services, as scheduled.
- Communicates the mission, ethics and goals of the hospital, as well as the focus statement of the department.
- Represents the organization in a positive and professional manner.
- Actively participates in performance improvement and continuous quality improvement (CQI) activities.
- Complies with all organizational policies regarding ethical business practices.
- Performs other duties as assigned
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High School graduate or equivalent.
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1 or more years of previous hospital experience required
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Experience with ICD-10 Coding preferred
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All employees must be fully vaccinated for COVID-19 or have applied for a religious or medical exemption prior to start date.
At McKenzie County Healthcare Systems, Inc., our commitment is to the patients and their families, whatever their needs might be. Our goal is to achieve the highest degree of healthcare for these patients and their families. We’re rural USA where we provide hometown values committed to quality services, continuity of care, assurance of qualified staff and family involvement for individual patients and clients.
McKenzie County Healthcare Systems, Inc. is here today because of the hard work and vision of community minded individuals. These people epitomize the spirit of work and caring that made McKenzie County the place it is today. They spoke of the “founders of our community” and how they “spent the vigor of their youth building up the way of life we enjoy today.” They felt a responsibility to provide quality healthcare to those pioneers. With that same attitude, we continue to work to provide healthcare services to those who chose to live and work in a rural area.
We are dedicated to the healing ministry of McKenzie County. We are committed to excellence and service in a person-centered environment that respects the human life of all, regardless of race, creed, color, national origin, disability, pregnancy, sex and/or marital status.
~McKenzie County Healthcare is an equal opportunity employer!