Medical Records Specialist Home Health

PruittHealth•New Bern, NC

About The Position

Medical Records Specialist – Home Health Services Home is where the heart is! That's why PruittHealth @ Home is committed to caring for our patients and residents, as well as providing our employees with a rewarding career as a member of our PruittHealth family. JOB PURPOSE: Reporting to the Branch Office Manager (BOM), the Medical Records Specialist (MRS) is responsible for maintaining medical records for the agency in a timely and accurate manner to ensure documentation flows from referral to final billing in an efficient and effective manner. The MRS maintains current patient information and enters activity into HomeCare HomeBase (HCHB) information system and processes and tracks medical records requiring manual and scanning processes. The MRS screens telephone calls for non-clinical issues.

Requirements

High school diploma or equivalent
None; on-the-job training can be provided

Nice To Haves

One (1) year working in a medical office environment.
Experience with Home Care Home Base (HCHB).
Any industry certification related to medical records processing.
Applicable college coursework or vocational/technical training.
Home health agency operations experience.

Responsibilities

Maintain the medical records of the agency.
Participate in agency back office daily operations as assigned by the BOM.
Retrieve, sort, scan, and assemble any paper or electronic medical records into proper chart order. Ensure that records are continuously updated, and that required documents are provided, signed, and dated according to agency standard operating procedures (SOPs).
Call hospitals and facilities to locate and confirm information, including but not limited to: patient, hospital, hospital reason, admission date, discharge date, room number and additional notes as applicable.
Log all collected patient information on spreadsheets, and email to clinicians and office staff.
Print completed Hospital Log and brings to daily Stand-Up to discuss needs for patients requiring transfer, OASIS, resumption of care (ROC) orders, and discharge.
Answer and evaluate needs and importance of calls related to patients and potential referrals. Assist clinicians with appropriate disposition of calls to the agency.
Process signed orders.
Review Order Tracking Report, Hospital Report and Face-To-Face (F2F) Report.
Fax approved orders and Physician’s Plan-of-Care (POC/485) to physician for signature.
Access and process medical records for F2F requirements. Fax to physicians to obtain signatures as needed.
Provide reports at Daily Stand-Up Meeting on number of total outstanding F2F’s, number of F2F’s given to Clinical Manager for review that day and those outstanding, total outstanding document numbers, total outstanding documents greater than 30 days out, filing and scanning status, and estimated time to complete outstanding items. Participate in discussion of hospital list and status of each patient.
Review and audit medical records according to agency SOPs for accuracy and completeness, e.g. billing attestation review.
Process requests for health information received from patient’s accounts, billing, etc.
Purge and archive medical records on an as needed basis and as recommended by agency SOPs.
Scan and access the location of medical records through a chart tracking system.
Utilize HCHB for workflow processing of records received, sent for signature, returned to the agency, and scanned and collated, and any hard records that remain onsite or for shredding processes. (This may include, but is not limited to, laboratory reports, nurses' notes, prescription, and other information located in the patient’s electronic medical record).
Access and process record for Face to Face (F2F) documentation, operative notes, discharge summaries, laboratory and radiology reports.
Communicate via fax with physicians' offices to obtain current visit notes and co-signatures from primary care physicians (PCPs),
May evaluate the needs and severity of phone calls from patients and assess appropriate disposition of call.
Participate month end billing processes and billing attestation processes and procedures.
Scan clinical records for new and current patients upon receipt of medical records.
Complete quantitative administrative review of clinical records at the start of care (SOC) and upon patient discharge.
File incoming documents daily. Maintain a control procedure for active patient files. Maintain a tracking system to ensure clinical records are current according to company SOPs and regulatory and accreditation requirements.
Track missing/late documentation.