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Description
Full-time, 30-40 hours/week
Monday-Friday, 8am-4:30pm, no on-call or holidays
Benefited position after 60-day waiting period.
JOB SUMMARY: Responsible for all aspects of chart completion and maintenance. Review medical records after patient discharge, for completeness and compliance with hospital policies. Communicate to physicians about delinquent reports.
PRIMARY RESPONSIBILITIES AND DUTIES:
- Enters deficiencies into computer for notification for physician completion
- Routing of all incomplete charts and checking for completion after physician has worked on his/her charts.
- Health Information Management
- Maintains knowledge in charting requirements
- Abstracts procedural and other information from the record on each inpatient, outpatients and Emergency Department visit into the electronic medical record after discharge
- Performs records requests and release of information for individuals or agencies in accordance with hospital regulations and statues of privileged information.
- Filing of medical records charts and loose reports to include scanning in documents (ex. Advance Directives) to complete electronic medical records
- Assembly and analysis of all discharged charts
- Completion of birth certificates and paternity affidavits
- Submit newborn hearing test results to the state
Requirements
EDUCATION/LICENSURE/CERTIFICATION:
- High School diploma or equivalent required.
EXPERIENCE:
- Knowledge of hospital information system desired.
- Experience in customer service environment desired.
- Experience with electronic health records.
- Ability to learn and utilize efficiently various hospital computer systems and/or programs
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