Location: all cities,GA, USA
JOB SUMMARY
The Health Information Management Record Assistant is responsible for creating, maintaining, and validating Hamilton Health Care's legal electronic medical records. Duties include retrieving discharged records and loose pages from nursing units and ancillary departments within the hospital. The paper records are reviewed for document and patient identifiers and then prepped for the scanning process. The paper is scanned on an approved scanners and image quality is reviewed for legibility. The electronic record is reviewed to validate the images are assigned to the proper doctype, folder and patient's medical record. 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. Retrieves medical records and pulls microfilm when appropriate. Thorough knowledge and awareness of work environment assuring a professional service and a high degree of quality at all times. To insure timely and accurate processing of all inpatient, observation and outpatient surgery discharged medical records and emergency room records.
Types and files all live birth and fetal death certificates according to established departmental procedures. The team member must be detailed oriented and be able to work independently. Must demonstrate initiative and ability to work with physicians and other healthcare providers with cooperation and flexibility. Must have good verbal, written and computer communication skills.
The team member has access to patient medical information, involved in ensuring the integrity of the legal medical record and must strictly uphold patient confidentiality. Performs other duties as assigned.
This position must practice good organizational skills due to interruptions and interactions with others. Position must be able to work in a team environment and also be self-directed enough to work alone with minimal supervision.
Qualifications
JOB QUALIFICATIONS
Education: High school graduate or GED equivalent required.
Licensure: None
Experience: Minimum of 2 years' experience in a HIM environment. One year of Medical Record and/or scanning experience preferred. Previous experience in a hospital HIM department preferred. Will consider medical office experience.
Skills:
* Accurate Typist.
* Fluent in Spanish preferred or minimum of knowledge of the Spanish language.
* Ability to examine the chart and verify patient identification utilizing the hospital-wide patient system.
* Strong knowledge of medical record format and content.
* Ability to identify non-standardized forms and determine action required.
* 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 navigate the patient registration system.
* Organized and attention to detail and quality.
* Ability to prioritize workload and strong recall and recognition skills.
* Ability to perform computer functions in a Microsoft Windows environment.
* Ability to push or lift 30 pounds.
* Good verbal, written and computer communication skills.
* Good decision-making.
* Detail oriented.
* Adheres to the facility's confidentiality policy for all information related to patient's, their family, staff, physicians and clients.
PHYSICAL, MENTAL, ENVIRONMENTAL AND WORKING CONDITIONS
Moderate amount of sitting with some bending or stooping. Requires moderate amount of working at a computer screen. Requires walking up and down stairs. Must have manual dexterity. Requires repetitive finger and wrist movement. This position requires a light amount of physical work, with maximum lifting of 20 pounds; frequent lifting and carrying; filing of medical records and documents weighing up to 10 lbs. Filing records requires reaching, pulling, pushing, bending, and stooping. 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 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.
* Work assignments require consistent periods of sitting or standing.
* Dexterity of upper extremities and fingers, as well as mental dexterity for accurately sorting medical record documents, utilizing and operating multiple windows of different software programs simultaneously.
* Ability to flex neck for sorting documents.
* Light to moderate lifting of 25 +/- pounds of medical record documents.
* Ability to stand, bend and stretch to accommodate filing and sorting process.
* Ability to communicate clearly and understandably on the telephone and in person.
* Ability to understand the spoken work on the telephone and in person.
This position must practice good organizational skills due to interruptions and interactions with others. Position must be able to work in a team environment and be self-directed enough to work alone. 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.