Medical Record Specialist 1.0
Lancaster General Hospital
9020 HIM-Medical Record Services
Health Information Management Medical Record Services
POSITION SUMMARY: To analyze patient charts for deficiencies, and either complete chart or assign deficiencies to providers. Serve as primary contact person for physicians in the completion of the electronic medical record. Compile, process, and maintain medical records of the hospital and its entities in a manner consistent with medical, administrative, ethical, legal and regulatory requirements of the health care system. Provide exceptional customer service by answering telephone calls and handle requests for medical records.
ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:
- Analyzes scanned records for chart deficiencies and assigns deficiencies per applicable regulations. Review all work ques and reassigns deficiencies to ensure timely completion of patient records.
- Verifies that the History and Physical referenced is complete and accurate based on the Rules and Regulations.
- Prepares and distributes documents such as physician reminder notices, and suspension lists.
- Review the demographic data for all portions of the record that are analyzed and report errors identified through OnBase corrections.
- Maintain confidentiality of all patient records and personal information according to HIPAA guidelines. Assist patients and or physicians with medical records requests.
- Performs related clerical duties such as photocopying, scanning, answering telephones, chart analysis in EMR, knowledge of EPIC, Microsoft Office. Knowledge of various types of imaging software. Oversee incoming faxes, interoffice mail, log and maintain Fetal Monitoring Strips. Organize and prioritize work tasks. Prepare FedEx deliveries.
- Knowledge of Healthcare Effectiveness Data and Information Set (HEDIS) measures and domains for participation in medical and chart audits when requested.
- Provide excellent customer service by being courteous, attentive and respectful to all patients, callers, and visitors as well as Penn Medicine Lancaster General Hospital employees/medical staff members. Insures understanding of customer requests and follow through, while being proactive in identifying concerns or problems. Resolve customer service matters in a polite and timely manner.
- Monitor the accuracy and appropriate maintenance of medical records on every patient insuring compliance with rules and regulations of state agencies, Joint Commission on Accreditation of health organization and medical staff bylaws.
SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:
- Assure continuous professional development of self and staff by attending Health Information Management and Medical Records Services meetings, lunch and learn seminars and training classes (Continuous improvement, Excel, etc) as scheduled. Adhere to facility standards concerning conduct, dress, attendance and punctuality.
- Ability to adapt to new processes, multi-task and respond to difficulty and challenging situations in a professional manner.
- Works within scope of position and direction with minimum supervision; willingly accepts assignments and is eager to take on additional responsibilities.
- Demonstrates ability to successfully adapt and perform during times of high volumes and/or high patient acuity census. Demonstrates skill to services both hospital and physician office staff.
MINIMUM REQUIRED QUALIFICATIONS:
- High School Education or equivalency.
- One year work experience in an office required, preferably a healthcare setting.
- One year of medical records experience is preferred.
- Minimum of one (1) year Microsoft application.
- Registered Health Information Technician (RHIT).
Attention/Concentration: The following level of ability is essential for the jobholder to focus on certain aspects of current experience and reject others.
- The position requires the ability to attend to more than one aspect of a situation simultaneously. It is highly likely that multiple task demands are going to be required of the individual at the same time. Other aspects of the position will require strong concentration skills. The individual must have the ability to voluntarily sustain concentration to a task over an extended period of time as a result of an effortful and usually deliberate heightened and focused state of attention.
New Learning and Memory: The following level of ability is essential for the jobholder to learn and retain material.
- A large portion of this position required reliance on verbal memory and new learning. Efficiency in processing of verbal information, either in written or spoken form, is a major requirement and prerequisite of the job. The individual must be able to attend to and process multiple bits of information simultaneously. The individual must be able to organize and categorize this information effectively so that later recall is feasible.
Problem Solving, Reasoning and Creative Thinking: The following level of ability that is essential for the jobholder to think (in order to solve a problem) by combining two or more elements from past experience or imaginative thought.
- The position required much autonomy of thought and problem solving. The individual must be able to apply principles of logical or scientific thinking to define problems. The individual must be able to think abstractly, which is manifested in the ability to form concepts, use categories, generalize from single instances, apply procedural rules and general principles, and be aware of subtle or intrinsic aspects of a problem. The development of hypothesis and potential solutions to problems involves careful interpretation, analysis and diagnosis. The individual must be able to collect data, establish facts, and draw valid conclusions. The individual must be able to think creatively with a degree of inventiveness, experimentation and intuition. They must be able to deal with a variety of concrete and abstract variables.
APTITUDES: The following are essential requirements of the position in relation to job-worker situations. These items describe how a worker must adapt, adjust, conform or act.
Variety and change: Ability to perform a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure involving significant differences in technologies, techniques, procedures, environmental factors, physical demands, or work situations.
EQUIPMENT USAGE REQUIREMENTS
Equipment/Tools: Computer, Phone, Copier, Printer, Fax, Office Supplies
Software: Microsoft Office Products, Epic, Pacscube, Xcelera, Roxio, OnBase, Fedex-Cardinal Optifreight
Rarely 0-10%; Occasionally 11-35%; Frequently 36-70%; Continuously 71-100%
• Sit: Continuously
• Stand: Occasionally
• Walk: Occasionally
• Bend: Occasionally
• Push: Rarely
• Pull: Rarely
• Kneel/Squat: Rarely
• Reach: Rarely
• Twist: Rarely
• Balance: Rarely
• Climb: Rarely
Lifting: Degree of physical exertion is: Moderate, exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
Sensory Abilities specifically required:
WORKING CONDITIONS: Exposure to hazardous conditions/ materials is negligible.
Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards. The percentages of time spent performing job duties are estimates, and should not be considered absolute. The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole. Incumbent must be able to perform all job functions safely.
Posted on 03/06/2020