Electronic Medical Records Specialist - FT - Days (72400)

Hamilton Health Care System•Cleveland, TN

About The Position

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.

Requirements

High school graduate or GED equivalent required
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.
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

Nice To Haves

Associate degree preferred
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.

Responsibilities

Creating, maintaining, and validating legal electronic medical records
Retrieving records from nursing units, ancillary departments, and remote campuses
Reconciling inpatient and outpatient discharged records against census reports
Reviewing paper records for document and patient identifiers
Preparing records for the scanning process
Scanning paper records on high-speed or flatbed scanners
Reviewing image quality for legibility
Manually indexing electronic images
Validating images are assigned to the proper doctype and folder
Maintaining individual pages and documents
Performing quantitative and qualitative analysis of medical records
Reviewing electronic medical records for missing documents and incomplete information
Inserting electronic deficiencies into the record and assigning them to the proper physician
Assisting physicians with completing deficiencies
Assisting physicians
Performing various office duties
Answering phones within the HIM department