HIM/MEDICAL RECORDS SPEC/TECH Part time

POSITION SUMMARY 

Under the general direction of the director (or designee), medical record department, this individual is responsible for processing all internal and external reports needing filing in the records; retrieval of permanent records; file new records and re-file continuing records; any other duties assigned by the Director of Medical Records. Employee works under continual, regular supervision. All work is carried out in accordance with the department’s approved policies and procedures. 

JOB RESPONSIBLITIES:  

1. Abstracts statistical data from discharged patient records using hospital abstracting system. 

1. Accurately codes admission, interim and final diagnoses using DSM and ICD coding manuals and their versions. 

1. Safeguards and preserves the confidentiality of patient identifiable information in accordance with hospital and departmental policy. 

1. Promotes a positive working environment and guest relations. 

1. Assumes and/or performs additional duties as requested. 

QUALIFICATIONS 

Education:  High school graduate or equivalent. 

Experience: A minimum of two (2) years experienced in HIM/medical records is required.   

Additional Requirements:  Possess basic clerical training, which includes computer skills, basic filing skills and fundamental knowledge of office procedures. Basic knowledge of medical content and sequence. Must be fluent in English, with special emphasis on alphabetization, also able to process work, using both alphabetical and numerical filing systems. The technician must possess relevant experience in clerical duties sufficient for individual development to the level of independent functioning with minimal directi

KNOWLEDGE/SKILLS:  

1. Must have knowledge of medical terminology, and be skilled in the use of DSM and ICD medical terminology. 

1. Must be able to perform assignments with minimal supervision;  

1. Must be able to perform concentrated and/or complex mental activity with frequent involvement in complex and/or highly technical situations; Must be able to work successfully under highly stressful conditions; 

1. Must be able to make sound, independent judgments based on scientific and/or ethical principles; 

1. Must be able to comprehend and perform oral and written instructions and procedures; 

1. Must be able to collaborate with other multidisciplinary team members in an appropriate fashion; 

1. Must be capable of adapting to varying workloads an work assignments on a constant basis; 

1. Must have effective comprehensive reading skills, strong communication skills, written and verbal. 

1. Must possess a valid California Drivers License in order to drive hospital vehicles or on hospital business. 

GENERAL WORKING ENVIRONMENT: Working conditions for all employees are as follows, but not limited to a psychiatric hospital setting; some risk involved in the event of aggressive patient(s); work load may include day, evening, night, weekend and/or holiday shifts.   

Mental demands described herein are representative of those which must be met by an employee to successfully perform the essential functions of the job, but are not limited to the ability to remain calm in a stressful environment; and the emotional stability, physical stamina and agility to handle stress and respond quickly and effectively to emergency situations. 

PHYSICAL REQUIREMENTS:  

• Must occasionally utilize physical ability for lifting or exerting force up to 25 lbs., climbing or balancing, and seeing with correction for peripheral vision. 

• Must frequently utilize physical ability for lifting or exerting force up to 10 lbs., and crouching or stooping. 

• Must regularly utilize physical ability for standing, walking, sitting, fingering or manual dexterity, repetitive finger motion, reaching or stretching, speaking, hearing and seeing with correction for close and distance vision, color discrimination, depth perception and focusing ability.Mental demands include but are not limited to emotional stability, physical stamina and agility to handle stress and respond quickly and effectively to emergency situations. 

CUSTOMER SERVICE 

Demonstrates a service focus in all interactions. 

• Demonstrates proper etiquette by acknowledging patients, guests, employees etc., promptly and by answering the phone properly (salutation, identify self and department, and within three rings). 

• Keeps customers informed by explaining procedures and updating them on changes, or delays in procedure. 

• Offers an explanation of reasons behind policies, procedures, and instructions (when possible). 

• Responds to information requests about the hospital and/or its programs within 24-hours to both community and professional external customers. 

MISCELLANEOUS 

• Assures department is maintained in clean and safe manner. 

• Complies with established measures for infection control, OSHA regulations and risk management. 

• Adheres to facility standards concerning conduct, dress, and attendance and punctuality. 

• Follows all facility, departmental and personnel policies and procedures.  Complies with the Employee Code of Ethics. 

• Attends regular staff meetings and department required functions. 

ATTENDANCE AND RELIABILITY 

• Reports to work on time for assigned shifts. 

• Maintains a good attendance record consistent with the hospital attendance policy. 

MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES: 

THIS SECTION DESCRIBES THOSE MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES AN EMPLOYEE IN THIS POSITION MUST BE ABLE TO USE. 

• Computer system and printer. 

• Telephone and paging system. 

• Copy, Fax, Scan machine. 

• Policies, procedures, plans and program manuals.