Transcriptionist - Acute

Summit BHC•Oakland, CA

About The Position

The Medical Records Specialist is responsible for qualitative workup of all medical records to include assignment of deficiencies, abstracting information for clinical indices, and preparation of chart for billing within set timelines. Maintains medical record integrity through filing, assembling, analysis and retrieving of confidential patient records in compliance with established patient confidentiality policies, regulations standards. May also be responsible for assigning ICD-10-PCS diagnostic and procedural codes to patient accounts codes and abstracts hospital medical records for maintenance of disease indices, internal and external reporting, research, compliance with federal, state and other regulatory agencies, and for billing and reimbursement.

Requirements

High school diploma or equivalent required.
A minimum of one year experience in Medical Records in psychiatric setting required.

Nice To Haves

Prior experience as an abstractor in a health information management or related health care field is preferred.

Responsibilities

Prepares and assembles medical records. Organizes and analyzes medical records for accuracy and completeness.
Establishes and maintains chart control, access and storage relating to the custody of chart and documents in accordance with established policies, procedures, and regulations.
Receives requests for information from medical records of patients in person, by mail, fax, from such sources as physicians, patients, lawyers, insurance companies, copy services, or health and welfare agencies. Logs in and out all incoming request for release of information identifying the date received, mailed and released information. Assures authorization are properly executed when responding to requests for medical information.
Manages provided transcription services. Searches and prints dictated reports from computerized transcription system.
Ensures files are stored in the designated area according to storage procedures. Pulls charts as requested for audits, peer review, readmissions, HBIPS processing and routes to appropriate area or department.
Processes reports for delivery of records for use in answering correspondence.
Compares signatures and forwards standard letters to requesting parties, following established policies and procedures on “the release of medical information.”
Performs quantitative and qualitative analysis of discharge records, assigns physician/clinician deficiencies, and monitors completion of those deficiencies.
Abstracts clinical information to maintain indices within specified time frames as required.
Identifies records for quality review monitoring or audits according to specified criteria and assists in retrieving and compiling data as requested.
Files pertinent clinical data in the appropriate chart, sets up and breaks down of discharge charts. Purges and inventories medical records for off-site storage.
Communicates with transcriptionist or transcription vendor to resolve issues/errors regarding reports.
Maintains Master Patient Index of all clients admitted into the facility.
Prints and delivers medical records forms to patient units. Picks up discharge records from patient units
May perform coding functions such as assigning appropriate codes using International Classification of Disease system (ICD-10) and/or Current Procedural Terminology (CPT) for diagnosis, procedures, and services.