Summary of essential job functions

• Demonstrates and understands the importance of and respect for the rights, dignity and individuality of each patient in all interactions.
• Coordinates daily activities and evaluates functions and procedures of the medical records department.
• Provides ongoing support and training as needed for all physicians utilizing dictation system and manages distribution of transcribed reports;

ensuring each is promptly placed with corresponding medical record.

• Provide monthly or daily reports as requested for departmental quality assurance and compliance in a timely manner to supervisor and other administrative committees.
• Develops and / or monitors specific departmental performance improvement plans as a result of audits, survey results and / or other specified reasons.
• Reviews and analyzes medical records for timely completion and documentation and communicates with providers any need for missing or ambiguous documentation required for a complete medical record.
• Oversees, monitors, reports and educates HIPAA Privacy compliance with facility employees regarding release of medical information according to company policies, state and federal statutes and laws.
• Provides input on new / updated policies in relation to content and context of the medical record.
• Organizes the storage, retrieval, archiving and destruction of medical records according to state statutes.
• Organizes and maintains Medical Staff credentialing files and presents completed initial and / or reappointment files to Medical Executive Committee and Board of Directors for approval.
• Maintaining a working knowledge of the Medical Staff Bylaws, applicable hospital policies and ensure familiarity with current accrediting agency standards, state and federal law pertaining to the Medical Staff and apply them to the credentialing process as needed.
• Serves as liaison between clinical, clerical and administrative staff in issues involving data acquisition and analysis.
• Provides direction, consultation and implementation of new programs related to medical records.
• Plan and prioritize assignments and develop departmental operations, ensuring effective use to time.
• Demonstrate technical knowledge of Health Information Management.

Standard Job Duties :

• Adheres to all components of the Hospital Compliance Plan in performing job duties and reports any violations or suspected violations of the Plan to the Compliance Officer.
• Demonstrates professional conduct and complies with hospital and departmental policies and procedures.
• Adheres to hospital attendance policy.
• Complies with measures for preventing exposure to bloodborne pathogens.
• Participates in the Hazardous Material Program; hazards include exposure to blood and body fluids, possible communicable diseases, sharp objects and instruments, assorted chemicals and gasses as listed in the Hazardous Materials Program Manual.
• Complies with established Safety and Patient Safety Program practices.
• Performs other incidental and related duties, as required and / or assigned.
• Develops an understanding of responsibilities for recognizing patient abuse and follows policy for making appropriate referrals / interventions.
• Develops an understanding of responsibilities for participation in Performance Improvement activities and participates in such activities.
• Limits access to protected health information (PHI) to the information reasonably necessary to do the job, and shares such information only on a need-to-know basis for work purposes.

Access to verbal, written and electronic PHI for this job has been determined based on job level and job responsibility within the organization.

Computerized access to PHI for this job has been determined as described above and is controlled via user ID and password.)

Qualifications :

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and / or ability required.

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Education / Experience :

Associates degree in Health Information Management or related area preferred .

Language Ability :

Math Ability :

Ability to perform basic math skills such as adding, subtracting, multiplying, and dividing.

Reasoning Ability :

Ability to apply common sense understanding to carry out instructions in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Computer Skills :

Knowledge of basic computer skills and word processing.

Certificates and Licenses :

Certification as a Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) .

Supervisory Responsibilities :

None

Work Environment :

The work environment is representative of that which an employee encounters while performing the essential functions of this job.

The noise level in the work environment is usually moderate.

Physical Demands :

The physical demands of this job are representative of those that must be met by an employee to successfully perform the essential functions of the position.

Reasonable accommodation may be made to a qualified individual with a disability who can perform the essential functions of this position with or without reasonable accommodation.

The employee must occasionally lift and / or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus while performing the duties of this job.

The employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; talk; and hear.

Last updated : 2024-06-07