Experience: One (1) year direct work experience with Healthcare Information Management functions.
Education: High School Diploma or Equivalency (HSE)
ESSENTIAL DUTIES, FUNCTIONS AND RESPONSIBILITIES
• Provides qualitative analysis, and evaluates medical records for internal consistency and completeness.
• Reviews and analyzes records to ensure they consist of correlation of laboratory test results, procedures, and treatments with diagnosis.
• Determines if the final diagnosis and procedures stated by the physician are valid and complete.
• Compiles and maintains daily, weekly, monthly and yearly statistics concerning Patient Registration and Admission, Discharge and Transfer (ADT) to ensure accurate patient census.
• Enters into the RPMS/ADT system and maintains the daily outpatient surgery information for statistical data, record maintenance and coding purposes.
• Monitors, logs, processes and distributes transcribed reports to proper physicians.
• Coordinates, trains, communicates and works collaboratively with the Information Technology staff relevant to the RPMS system ensuring the software are updated.
• Scans patient medical information into Electronic Health Record (EHR) with accuracy and timeliness.
• Imports patient information through Health Information Exchange into EHR and imaging systems.
• Creates Personal Health Record accounts for patient and checks Direct Messaging) daily.
• Processes Release of Information requests for patient information within 30 days of request and update RPMS Release of Information Package for tracking and accounting of disclosures in accordance with best practices, Federal and state regulations when applicable.
• Ensures routine telephone calls, visitors, questions for information relating to patient information, directions, and instructions are answered correctly and in a positive timely manner.
• Ensures new employees, practitioners and other hospital staff are orientated and trained about specialized medical record functions as related to their functions.
• Ensures and participates in continuous quality improvement monitoring on routine basis relating to job functions.
• Reviews, purges and prepares patient information, such as the paper medical records and logs, for shipment to Federal Archive Record Center and FILELINEACCESS. Updates
control logs and assists HIM team to convert all paper medical records into an electronic format using EHR, RPMS, and Vista Imaging.
• Registers patients using RPMS and geographical user interfaces when available, retrieves medical records and dispatches to proper hospital areas in an emergency contingency plan through paper or an electronic format in EHR
• Completes birth and death certificate registrations within seven (7) days in accordance with Arizona State Vital Records Regulations.
• Maintains log, interview patient and/or family members, and submits to Arizona State Registrar using web-based portal and follow up with providers, Arizona Vital Records, Funeral Homes and Criminal Investigators when needed.
• Issues medical record numbers for new patients and maintains a number control log on all medical records numbers issued. Maintains master patient index.
• Dispatches patients’ medical records to various ambulatory clinics and inpatient units as needed.
• Collects and returns the finished patient medical information from the clinics to the HIM Department.
• Logs and tags medical charts to assure appropriate delivery. Ensures charge out-cards are updated and recorded.
• Performs other duties as assigned.