Job Objective:
Under the supervision of the Assistant Director of Health Information Services and under the direction of the Service Coordinator will perform a variety of duties related to record processing including: quality control; validation processes; data entry; researching patient information; prepping records; scanning records; chart review and chart deficiency analysis; release of information; and record retrieval, filing, and delivery. This position will maintain daily workflow, ensuring timely processing of records with a high level of quality.
Duties and Responsibilities:
A. Quality Control/Validation
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- Performs quality control/validation processes to ensure all documents are assigned the appropriate document name and all documents are scanned into the correct patient folder with the highest level of quality.
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Identifies and rescans incorrectly positioned and poor quality documents.
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Inserts, appends, and merges documents when and where appropriate.
B. Prepping
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- Technically evaluates, preps, and processes documents in preparation for the scanning process while ensuring correct patient identification on each page of record.
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Processes photographs and cold feeds as defined in the guidelines.
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Removes staples, identifies poor originals, secures damaged or small documents.
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Prepares batches and completes appropriate information on cover sheet for each patient type.
C. Scanning
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- Scans documents in a timely manner while verifying accuracy of preparation, quality, and potential scanning hazards. Writes batches to correct work queue.
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Maintains scanner and performs scanner maintenance processes.
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Assigns a batch identification number according to procedure.
D. Chart Reviews and Chart Deficiency Analysis for Emergency Department and Ambulatory Surgery patients.
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- Reviews each discharged patient’s record for incomplete or missing items and identifies the responsible practitioner for each of these items.
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Enters physician deficiency data in the chart completion system or other system for regulatory reviews.
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Scans reference documents as appropriate.
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Monitors chart completion queues and other queues as assigned to ensure records are completed appropriately.
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Verifies physician dictation in dictation system if physician has documented dictation complete.
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Routes unidentified, incorrectly positioned, and poor quality documents to the documentation correction queue.
E. Release of Information
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- Copies, prints, or faxes pertinent records in response to requests for release of records or continued care.
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Documents or communicates requests or releases of records in appropriate system or to appropriate staff.
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Protects the confidentiality of primary and secondary health records and releases information as mandated by law, professional standards, and the hospital's policies.
F. Record Control
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- Retrieves, reproduces, delivers and files health information throughout the facility and in offsite storage areas using numerical, alphabetical, and color coded systems.
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Retrieves and reconciles daily discharge records to ensure timeliness of prepping, scanning, and quality control/validation.
G. Other Duties
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- Assists hospital staff, medical staff, public, and patients.
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Performs transcription clerical functions.
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Plans, organizes, prioritizes, and coordinates work to achieve functional area goals and maximum productivity and efficiency on a day to day basis.
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Researches and enters patient data into various systems as defined by procedure.
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Answers telephones consistent with Service Excellence standards, addresses and/or routes calls appropriately and in a timely manner.
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Reviews assigned work queue(s) daily and ensures timely processing of all assignments in queues.
Non-Essential Duties:
Accepts and carries out other miscellaneous duties and responsibilities as required for maintaining the services provided by Medical Records.
Knowledge, Skills and Abilities:
Knowledge
Knowledge of Microsoft Office applications.
Knowledge of department policies, practices and operations.
Skills
Perform data entry accurately with use of a keyboard and mouse.
Perform duties using computers and equipment required for scanning and indexing of documents
Effective oral and written communication skills.
Detail oriented and organized.
Abilities
Ability to recognize colors associated with color-coded filing system.
Ability to learn the advanced aspects of the various indexes, storage, tracking, and retrieval systems.
Ability to retrieve, reproduce, deliver, track, and file records using various equipment and systems in the facility and offsite.
Ability to review records and verify patient information.
AVH Values: All AVH employees will effectively demonstrate these values:
Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.
Education and Experience:
Education
Experience
Required Licensure and/or Certifications:
AVH Conduct/Compliance Expectations:
Ability to adhere with AVH Absenteeism and Tardiness Policy
Ability to adhere with AVH Leaves of Absence Policy
Ability to adhere with AVH Paid Time Off (PTO) Policy
Ability to adhere with AVH Recording of Hours Worked Policy
Ability to adhere to the department dress code
Ability to organize work and establish priorities
Ability to expand on own initiative in performance of duties
Skill and ability to follow the telephone etiquette/standards
Conforms to AVH Standards of Excellence
Ability to function effectively under pressure and meet time parameters
Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff
Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVH
Ability to maintain the confidentiality of patient, hospital and department information
Ability to adhere to safety rules and regulations
Safely and effectively uses all equipment necessary to carry out duties
Ability to interpret and function under hospital and department policies and procedures
Conforms with required and appropriate Joint Commission requirements
Conforms with and supports hospital quality assurance and improvement guidelines
Ability to participate effectively in department and hospital staff education
Display a willingness to work as a team player
Ability to give and support the highest level of patient/customer satisfaction at all times
Supports and adheres to the values and mission statement established by the AVH Board of Directors
Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
Ability to follow the Code of Conduct
Physical Requirements and Working Conditions:
Work is usually performed in a normal office environment and may require long periods in sedentary position performing one function.
Trips within the facility and to onsite storage areas will be required to retrieve or deliver records.
Frequent use of scanner, keyboard and video display terminal.
A detailed description of the physical requirements of this job is maintained in the Employee Health Department.
NOTE: THE ABOVE STATEMENTS ARE INTENDED TO DESCRIBE THE GENERAL NATURE AND LEVEL OF WORK PERFORMED BY PEOPLE ASSIGNED TO THIS JOB. THIS DOCUMENT IS NOT INTENDED TO BE AN EXHAUSTIVE LIST OF ALL RESPONSIBILITIES, SKILLS, AND WORKING CONDITIONS FOR THE PERSONNEL SO CLASSIFIED.
Education and Experience:
Education
Experience
Required Licensure and/or Certifications:
PLEASE NOTE: This is for a Saturday, Sunday and Monday only work schedule