Essential functions includes, but is not limited to the following:

• Prepare patient’s chart before the patient is seen; i.e. printing patient data sheets, financial policy, GYN update form, OB questionnaire, HHQ form, and/or HIPAA. Have the chart ready for check in the day prior to the appointment. Includes add on appointments.
• Reviews and scans all patient records/documents to ensure all forms are completed, properly identified, signed, and that all documents are filed under the correct document type and filed into the correct patient’s chart. Also, includes filing the fax server, ICS batches, and ultrasound reports.
• Communicates as needed with physicians and other health care professionals to obtain any additional information that may be needed to ensure proper treatment of the patient.
• Uses computer programs to submit records requests, FMLA/disability paperwork to physicians as requested for review, quality assurance checks, and other purposes. Uses computer programs to update and complete diagnostic orders to tabulate and analyze data to improve patient care, meet meaningful use stages, respond to surveys and/or used in research studies.
• Provides charts/documents requested for use in legal actions, following patient consent and confidentiality protocols. Follows up with physicians to ensure timely processing of requested records/documents. Follows the Texas Medical Board rule 165.2 for the medical record release and charges.
• Prepares surgery charts before the patient surgery date. Ensures the charts have the appropriate forms needed for the surgery; post op instructions, sterilization consent form, GYN master, OB master, surgery scheduling order form and/or surgery charge sheet.
• Audit and retrieves any missing operative reports prior to the patients post-operative visit.
• Processes ACOG’s, referrals, CCD continuity of care to other providers and hospital facilities as requested in a timely manner.
• Processes, separates, and delivers incoming/ outgoing inner office mail and mail received by the post office to appropriate physicians or staff members on a daily basis.
• Reviews and responds to telephone messages, emails, patient portal request, and work-log manger task on a daily basis.

Education

• High School Diploma or General Equivalency Diploma (GED)
• Associate’s degree from a community/junior college preferred.

Other Requirements

• Registered Health Information Technician (RHIT) designation preferred, but not required. Offered by the American Health Information Management Association; designation awarded after successfully completing written exam.
• Current health records with the appropriate immunizations to work in the health care field (hepatitis B and tuberculosis) may be required.

Performance Requirements

Knowledge

• Knowledge of medical records work procedures.
• Knowledge of computer applications.
• Knowledge of medical terminology.
• Knowledge of legal and ethical considerations related to patient information.

Abilities

• Ability to alphabetize and put information (materials, forms, etc.) into chronological order.
• Ability to analyze medical records for completeness and accuracy, paying attention to detail.
• Ability to schedule time and assignments effectively.
• Ability to establish and maintain courteous and professional working relationship with other staff and patients.
• Ability to work on several projects simultaneously.

Equipment Operated

• Range of medical records equipment and supplies, including computer hardware/software, manual files, and sorters.

Work Environment

• Usually pleasant and comfortable offices. Little contact with patients.

Mental/Physical Requirements

• Must be able to lift up to 10 pounds of supplies.
• Combination of standing, sitting, bending, and reaching. May work at computer monitors for prolonged periods with danger of eye strain and muscle pain.
• Stress generated if workload is heavy.

Experience

• Minimum two years of medical records clerk/health information technician experience, preferably in medical practice setting.

Education

• High School or better

Skills

• Planning/Organizing Skills
• Communication Skills
• Computer/Tech Literacy
• Medical Office Procedures

Behaviors

• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

• Team Player: Works well as a member of a group

Motivations

• Self-Starter: Inspired to perform without outside help
• Flexibility: Inspired to perform well when granted the ability to set your own schedule and goals