What are the responsibilities and job description for the Medical Records Clerk / HIM Technician position at GRAHAM REGIONAL MEDICAL CENTER?
Job Type
Full-time
Description
ORGANIZATIONAL DESCRIPTION
The HIM Technician is responsible for processing medical records, responding to telephone requests for charts and other information and performs other duties as assigned in the Health Information Department according to policy and procedure. This position reviews, corrects and analyzes data from the medical record for deficiencies or delinquencies to ensure records are complete, accurate and in compliance with regulations.
INTERACTION
Primarily Interacts with: administration, physicians, employees, clinical and non-clinical departments, and patients.
PRIMARY FUNCTIONS
- Analyze and submit any deficiencies to physicians per CMS guidelines.
- Retrieve and review any records for physician completion.
- Obtain signatures from providers in a timely manner.
- Ensure initial chart is final and complete.
- Collect and discharge patient records.
- Collect loose filing for discharge records.
- Assemble record according to assembly list.
- Forward records for labeling of forms.
- Assist in answering telephone and taking accurate messages.
- Assist and perform in release of information.
- Maintain hospital daily census. Abstract and maintain observation / ER log
- Assist with Performance Improvement
- Provide exemplary customer service.
- Maintain confidentiality and compliance with HIPAA.
- Cooperate with other personnel to achieve departmental objectives and maintain good employee relations, inter-departmental objectives and infection control policies.
- Cordially demonstrate timeliness and professionalism in appearance, communications, and actions during all interactions and with all individuals and entities.
- Solve practical problems, dealing with a variety of issues, and interpret a variety of instructions furnished in written and oral form.
- Attend meetings as required.
- Perform other duties as requested or assigned.
Requirements
ABILITY TO USE EQUIPMENT, TOOLS, MATERIALS, MACHINES: Computer, telephone, facsimile machine, copier, scanner, printer, calculator and other standard office equipment.
EDUCATION/EXPERIENCE/SKILLS/ABILITIES
Education:
- High school diploma or GED required; Associate’s degree or higher preferred.
- Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification strongly preferred.
Experience:
- Medical experience preferred.
- Acute Hospital Setting experience preferred.
Personal Job-Related Skills / Abilities:
- Medical terminology knowledge required: APCs, DRGs, ICD -9, ICD-10 and CPT-4.
- Knowledge of medical staff by-laws, rules, and regulations.
- Knowledge of HIPAA privacy information standards required.
- Must be committed to quality and patient safety at all times.
- Excellent command / highly proficient in spoken and written English.
- Basic computer skills, including but not limited to: Microsoft Office, scheduling and payroll systems, electronic medical documentation, and email.
- Must be effective at adjusting to change, prioritizing duties, handling stress and effectively communicating face-to-face and/or over the telephone.
- Must be able to work independently, and flexibly, and as a part of a multidisciplinary team.
- Must be able to manage several interruptions throughout the shift.
- Must have strong interpersonal and communication skills, verbal and written.
- Must have strong time management skills.
- Must be able to work under pressure while interacting in a helpful, courteous manner with a high degree of patient contact.
- Sufficient hearing, vision and dexterity to perform duties safely.
Physical and Mental Requirements:
Physical:
Activity Up to %
- Walking 25
- Squatting 10
- Standing 25
- Pulling 10
- Kneeling 10
- Reaching 35
- Sitting 80
- Lifting up to 30lbs 20
- Pushing 10
- Wrist/Finger Movements 90
- Bending 25
- Climbing 1
Mental:
- Stress Level Moderate
Individual position core competencies:
- Quality
- Service Excellence
- Compassion
- Professionalism
- Fiscal Responsibility
Required education within first 60 days (if employee is from outside organization).
- GrahamRMC Orientation
- Department Orientation
Continuing/Annual Education and Training:
- As needed to maintain certification/ licensure of position
- Falling Star Program
- Safety Storm Program
SUPERVISION
Employees Supervised: __No__
ADA REQUIREMENTS
Each category is grouped under a percentage rating based on the frequency the condition is expected to occur.
Frequency of Condition 1-33% 34-66% 67%
1-33%
- Extreme Heat
- Extreme Cold
- Extreme Swings in Temperature
- Extreme Noise
- Working Outdoors
- Mechanical Hazards
- Electrical Hazards
- Explosive Hazards
- Fume/Odor Hazards
- Dust/Mite Hazards
- Chemical Hazards
- Toxic Waste Hazards
- Radiation Hazards
- Wet Hazards
- Heights
- Other Conditions
67%
- Working Indoors
OSHA Classification:
Identify with a check the OSHA Job Category that describes this job. The intent is to enhance worker protection by identifying any risk in the performance of routine and reasonably anticipated job-related functions.
_____ Category I: Tasks that involve exposure to blood, body fluids or tissues.
All procedures or other job-related tasks involve an inherent potential for mucous membrane or skin contact with blood, body fluids or tissues or a potential for spills or splashes of them are Category I tasks. Use of appropriate protective measures, such as gloves, masks, goggles, and gown are required for every employee engaged in Category I tasks.
_____ Category II: Tasks that involve no exposure to blood, body fluids or tissues but employment may require performing unplanned Category I tasks.
The normal work routine involves no exposure to blood, body fluids or tissues, but exposure may be required as a condition of employment. Appropriate protective measure, such as gloves, masks, goggles, and gown are readily available to every employee engaged in Category II tasks.
__X__ Category III: Tasks that involve no exposure to blood, body fluids or tissues and Category I tasks are not a condition of employment.
The normal work routine involves no exposure to blood, body fluids or tissues (although situations can be imagined or hypothesized under which anyone, anywhere might encounter potential exposure to body fluids). Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or first-aid or to be potentially exposed in some other way. Tasks that involve handling implements or utensils, use of public or shared bathroom facilities or telephone and personal contacts such as handshaking are Category III tasks.
ADDITIONAL INFORMATION
The employee will demonstrate continuous commitment to the maintenance of a clean and safe work environment that is compliant with applicable regulatory agency requirements. The employee will follow established infection control procedures.
The employee will ensure the effective and safe use of all equipment used in his/her activities, if applicable.
The competence of the employee in performing his/her job duties is evaluated during orientation to his/her position and will be demonstrated, maintained, and improved on an ongoing basis. The employee will adhere to the assigned schedule and report to work on-time.
The employee shall abide by the requirements set forth in the Code of Conduct and report suspected violations of the Code of Conduct.
The employee will recognize, appreciate and incorporate an employee’s, patient's and patient’s family's unique differences, such as culture, spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age, and values, into an individualized plan of care or plan of action.
The statements contained in this position description reflect the general duties considered necessary to describe the principal functions of the job as identified, and shall not be considered a detailed description of all the work requirements that may be inherent in the position. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.
The job description does not constitute a contract of employment and the company or employee may exercise its employment-at-will rights at any time.
LEADERSHIP ADVISORY ADDENDUM
I understand as a Department Head I am responsible, either personally or through delegation, for:
- Integrating the service into the organization’s primary functions.
- Coordinating and integrating interdepartmental and intradepartmental services.
- Developing and implementing policies and procedures that guide and support the provision of services.
- Recommending a sufficient number of qualified and competent persons to provide care, including treatment and quality customer service.
- Determining the qualifications and competence of department personnel who provide patient care services.
- Continuously assessing and improving the performance of care and services provided.
- Maintaining quality control programs, as appropriate.
- Orienting and providing in-service training and continuing education of all persons in the department.
- Recommending space and other resources needed by the department.
- Participating in the selection of sources for needed services not provided by the department or the organization.
- Develop, revise, recommend, and interpret policies and procedures for department to ensure all applicable laws and governmental guidelines are followed and that employees are treated in equitable manner.
- Select, orient, train, schedule, assign, direct and supervise department personnel. Evaluate work performance and initiate or recommend personnel actions such as merit increases, promotions, demotions, transfers, disciplinary action, and/or termination.
- Maintain effective and appropriate staffing by collaborating on recruitment and selection of qualified candidates, monitoring employee turnover, overtime, and absenteeism.
- Act as a role model in all settings using standard precautions.
- Consistently and fairly implement human resources policies.
- Perform and facilitate completion of department performance evaluations and competency assessments in a timely manner.
- Responsible for accuracy of department payroll; including approval via KRONOS. Manage time to stay within budgetary limitations. Adjust staff in relation to projects needing completion
In addition, as an employee responsible for the selection, supervision and/or guidance of others in the workplace I understand I am responsible to:
- Comply with District policy, equal employment opportunity requirements and applicable federal, state and local laws in all personnel activities in my area of responsibility.
- Provide a workplace free from harassment, hostility and offensive behavior.
- Maintain documentation to support action taken with personnel to include applicant/interview flow logs, questions asked during interviews, interview evaluation sheets for hiring decisions, and corrective actions.
