Medical Records

Cumberland River Behavioral Health Inc•Pittsburgh, PA

9h•Hybrid

About The Position

This role is responsible for the overall operation of the Medical Records/Intake program, ensuring the accuracy, content, and completeness of client files. The position involves coding diagnoses, maintaining records, and providing clerical support. The individual will also be involved in screening new consumers, scheduling appointments, processing billing, and verifying insurance coverage. Additionally, the role requires responding to emergencies, managing medication storage, and maintaining client confidentiality.

Requirements

High School Diploma or GED
Computer and typing skills
Organizational skills
Submitting to and passing successfully a criminal record check and a drug screening test.
Oral and written communication skills
Interpersonal skills
Ability to exercise good judgment, tact, diplomacy and compassion when problem solving, handling conflict or in a crisis situation
Ability to complete record keeping in a timely fashion
Ability to get along with diverse personalities and maintain effective working relationships
Ability to work well with people of all races, backgrounds and needs
Ability to work as part of a comprehensive community mental health team and to positively represent the agency in the community
Physically able to reach, push, pull, stoop, bend, stand, walk and lift up to 20 pounds
Possess a valid Driver’s License and maintain a safe driving record if required for job performance
Apply and receive a certificate for being a Notary in the State of Kentucky if required for job
All staff are required to participate in yearly trainings regarding infection control and safety in the environment including hazardous waste and blood borne pathogens.
All new staff must receive training regarding handling physical, verbal threats, acts of violence or other escalating and potential dangerous situations including when police need to be summoned.
All staff must be certified in Cardiopulmonary Resuscitation within one month of employment and maintain the certification.

Responsibilities

Assist in planning, organizing, directing and evaluating the overall operation of the Medical Records/Intake program.
Assisting in policy, procedure and system development and implementation for the overall operation of Medical Records/Intake program.
Assist in keeping staff informed of new changes and relevant issues.
Ensures the accuracy, content and completeness of all client files.
Assist with the overall operation of the outpatient office by providing relief and coverage.
Responsible for coding diagnoses and ensuring current diagnoses in the medical record.
Maintaining and establishing Client II Medical Records files.
Responsible for ensuring completeness of terminated files prior to keying discharge.
Responsible for copying records for Social Security Disability, attorneys, and the consumer as requested, per agency policy.
Responsible for the daily scanning and maintenance of the medical record.
Responsible for sorting all terminated medical records in preparation for storage when no longer required in the outpatient office (adult charts – seven year, children charts – seven years past their 18th birthday).
Responsible for maintaining client confidentiality at all times.
Respond to emergency situations in a timely manner.
Conduct monthly inspections of the Medication Storage area and Medication Sign In/Sign Out logs for all sample medication. Responsible for sending all outdated medications to the appropriate Regional Site for disposal. Disposing of all medication is documented by completion of log of medications.
Demonstrate the ability to work effectively with other team members, as part of a multidisciplinary team, and independently, when necessary.
Answer telephone in a polite, helpful manner and transfer to appropriate staff members as indicated.
Screen all potential consumers of services utilizing the Admission Outpatient form in Avatar.
Instruct all new admissions of the necessary documentation to be brought to the first appointment.
Schedules all appointments per agency policy for all clinicians, nurse practitioners and psychiatrists.
Greet consumers in a friendly helpful manner.
Perform general clerical duties to include but not limited to: photocopying, faxing, mailing, and scanning.
Place reminder calls to all consumers who are scheduled the next day and follow up calls to those that do not keep appointments within twenty four hours of missed appointment.
Enter all client medications and allergies into Order Connect.
Process billing documents by ensuring completion of all required fields on service ticket and ensuring that note is entered in the medical record with all required fields.
Logging all billing documents on patient registers and forwarding all billing documents to the main office as required.
Process cash payments per agency policy.
Verify Medicaid/Insurance coverage per agency policy.
Complete vitals and enter into electronic health record.
Other duties as assigned.