Medical Records Clerk St. Francis Hospital - Delaware - Wilmington, DE High School/GED 2-5 years required Job Title: Medical Records Coordinator Supervised by: Quality Assurance/ Compliance Manager Job Purpose: Under the supervision of the Quality Assurance / Compliance Manager: Is responsible for the management of electronic health records (EHR) and paper medical records, and data necessary to ensure timeliness and overall quality and completeness of all clinical documentation is in accordance with Saint Francis LIFE Policies and Procedures, all accrediting organizations, and state and federal rules and regulations Performs interval EHR and paper medical record audits Interacts with physicians, nursing staff and coding/finance staff to ensure that all clinical activity is appropriately documented Performs scanning and indexing of medical records, and releases personal health information in accordance with the Health Insurance Portability and Accountability Act (HIPPA) and Protected Health Information policies and procedures. Supports the Quality Assurance / Compliance Manager’s implementation and analysis of Quality and Compliance data to identify areas for improvement Major Duties and Responsibilities : Implements and maintains all technical and administrative operating systems of EHR, including procedures, methodologies, and performance standards for LIFE in accordance with all regulatory agencies Works closely with intake and enrollment staff, to obtain past medical records for all prospective enrollees prior to their assessment by the interdisciplinary team to include contacting and retrieving records from physicians, hospitals, and nursing homes as well as other medical providers Responsible for ensuring that past medical records are accessible for review by the LIFE primary care provider and the Interdisciplinary Team (IDT) Establishes and enforces procedures to insure the confidentiality of medical information. Works closely with the Quality Assurance / Compliance Manager to protect the rights of the participants and staff members Through analysis, assists the Quality Assurance / Compliance Manager to identify areas for improvement and develop corrective action plans Assists the Quality Assurance / Compliance Manager with quarterly Quality Assurance Committee and Compliance/FWA Committee meeting preparations to include agenda development, recording minutes, copying reports for distribution in the meeting Maintains and preserves paper medical records for all participants including a system for indexing and filing medical records in accordance with standards established by Saint Francis LIFE and regulatory agencies Reports to the Quality Assurance / Compliance Manager on productivity, statistics, project progress and areas identified for improvement Files and retrieves records and documents daily and as requested Audits EHR and documents for completeness and compliance with established procedures and alerts staff when documentation is not complete Reports EHR audit results/analysis to the Quality Assurance / Compliance Manager Performs all functions related to medical records in keeping with regulatory standards and Saint Francis LIFE policies and procedures Prepares copies of medical records as requested Continues self-education for application of new and improved processes Understands, supports, and communicates organizational mission, vision, and values Acts as primary coordinator for HIPPA implementation and ongoing compliance Supports IDT Facilitator and team members through accurate recording of IDT Morning Meeting Minutes and Care Planning Sessions. Minimum Qualifications and Requirements : Education: High school diploma or equivalent Experience: One year of experience in Medical Records or other clinical setting Proficient in data entry and Microsoft Word, Excel and/or other data software Possess: Knowledge of medical records documentation requirements care. Highly organized and accurate. Knowledge of medical terminology Good organization skills, self-starter, demonstrates initiative. Skilled in establishing and maintaining effective working relationships with patients, co-workers, medical staff, and the community Skilled in identifying, analyzing areas for improvement and develop corrective action plans Ability to work independently with minimum supervision. Ability to communicate clearly and effectively
Posted on: Wed, 21 Jan 2015 03:09:28 +0000
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