Electronic Medical Records Specialist - FT - Days

JOB SUMMARY

The Electronic Medical Records Specialist is responsible for creating, maintaining, and validating Bradley Health Care’s legal electronic medical records. Duties include retrieving records from nursing units, ancillary departments, and remote campuses. All inpatient and outpatient discharged records are reconciled against census reports. The paper records are reviewed for document and patient identifiers and then prepped for the scanning process. The paper is scanned on either high-speed or flatbed scanners and image quality is reviewed for legibility. Electronic images which require manual intervention are manually indexed to the assigned the document or patient id. The electronic record is reviewed to validate the images are assigned to the proper doctype and folder. Individual pages and documents are maintained as needed including moving or rotating pages, reassigning documents to the proper encounter, splitting pages into multiple documents, and merging different documents into one.

The position performs quantitative and qualitative analysis of medical records of discharged Inpatient, Observation, and Outpatient Surgery records in accordance with Medical Record policies and procedures, Medical Staff policies, JCAHO and other regulatory agency standards. The electronic medical record is reviewed for missing documents, incomplete information on existing documents, and missing signatures to ensure the record is complete and accurate. Electronic deficiencies are inserted into the record and assigned to the proper physician to complete. Changes to the record that require reanalysis are also reviewed and additional action is taken as needed. Assistance is provided to physicians as needed when they are completing their deficiencies.

Other periodic duties include assisting physicians, various office duties, and answering phone within the HIM department.

JOB QUALIFICATIONS

Education: High school graduate or GED equivalent required Associate degree preferred

Licensure: N/A

Experience: Minimum of 2 years experience in a HIM environment or 3 years of experience as a HIM Analyst preferred.

One year of Medical Record and/or scanning experience preferred. Must demonstrate the ability to type 40 - 45 wpm accurately or demonstrate sufficient keyboard familiarity to perform job functions. Previous experience in a hospital HIM department preferred.

Six months of analysis experience preferred. Previous experience with a document imaging system desired, preferably Siemens Imaging; will consider medical office experience.

Skills: 

• Strong knowledge of medical record format and content for inpatient and outpatient visits.

• Orientation to anatomy and physiology as well as medical terminology.

• Ability to examine the chart and verify patient identification utilizing the hospital-wide patient system with complete knowledge of the registration process and pathways.

• Ability to examine a form and determine its proper barcode.

• Ability to identify non-standard forms and determine action required.

• Ability to navigate the patient registration system.

• Ability to perform computer functions in a Microsoft Windows environment.

• Ability to push or lift 30 pounds.

• Good verbal, written, and computer communication skills.

• Detail oriented.

• Ability to evaluate and process 400 documents per hour.

• Adheres to the facility’s confidentiality policy for all information related to patient’s, their family, staff, physicians and clients.

• Ability to prioritize workload and strong recall and recognition skills

PHYSICAL, MENTAL, ENVIRONMENTAL AND WORKING CONDITIONS

Typical office/information systems environment, subject to frequent interruptions and heavy deadline requirements.

The associate is frequently working with sensitive and confidential patient and business information.

Frequent sitting, and long periods of reviewing records from a computer screen. Frequent pushing, pulling, bending, stooping, reaching and climbing (steps, step ladder, stool) requires use of proper body mechanics. Often it will be necessary for individual to spend most of shift on feet. Ability to handle moderate to heavy materials while bending or reaching overhead. Dexterity of upper extremities and fingers, as well as mental and visual dexterity to names, numbers, color codes, report types, as well as hand dexterity to sort reports and/or enter data.

1. Work assignments require consistent periods of sitting or standing.

2. Dexterity of upper extremities and fingers, as well as mental dexterity for accurately sorting medical record documents.

3. Ability to flex neck for sorting documents.

4. Light to moderate lifting of 25 +/- pounds of medical record documents.

5. Ability to stand, bend and stretch to accommodate filing and sorting process.

6. Ability to communicate clearly and understandably on the telephone and in person.

7. Ability to understand the spoken work on the telephone and in person.

WORKING CONDITIONS

This position must practice good organization skills due to interruptions and interactions with other team members. Position must be able to work in a team environment and be self-directed enough to work alone when necessary. Must remain calm under stress and must be able to appropriately handle an irate person when the occasion arises (i.e., physician, hospital employee, patient).

Must be able to lift, bend and carry light to medium weight equipment. Move mobile files and buggies.

Full-Time Benefits

• 403(b) Matching (Retirement)
• Dental insurance
• Employee assistance program (EAP)
• Employee wellness program
• Employer paid Life and AD&D insurance
• Employer paid Short and Long-Term Disability
• Flexible Spending Accounts
• ICHRA for health insurance
• Paid Annual Leave (Time off)
• Vision insurance