Job Description

Summary of Duties Responsible for the day to day operations and work flow of the medical record department, including responsibility for record integrity, record retrieval, storage and supervision of records. Administers, maintains and ensures the accurate documentation of the medical records. Coordinates medical record functions to include record maintenance of open and closed records and provides clerical support by filing documents, retrieving charts, and responding to request for information. Essential Job Functions Prepares and maintains medical records, forms, registration materials and other related documents Maintains medical records files, including concurrent and retrospective medical record analysis and notifying physicians of any delinquencies or outstanding medical record issues Provides medical record scans to the home office coding department in accordance to policy and procedure to maintain an accurate DRG assignment for all patients Enters the required information into the LTRAX system as required Assembles, analyzes and completes medical records after discharge Completes closed chart audits on all discharge charts Completes medical record audits for performance improvement activities as required Interacts and communicates with medical and professional staff to assist with audits and completion of medical record chart deficiencies. Ensures medical records are complete prior to audit Receives, reviews and coordinates loose reports for filing on all records as directed Safeguards confidentiality of the medical record and complies with all local, state and federal laws pertaining to medical records. Assures compliance with all HIPAA regulations concerning use, retrieval, storage, and sharing of medical records Evaluates and responds to requests for the release of medical records as outlined in policies and procedures, while ensuring the highest degree of confidentiality, excellent service, accuracy and timeliness Oversees the release of information for continuity of care and patient transfer Prepares, maintains, and submits vital statistics reports as required Maintains monthly statistics and prepares reports in compliance with the Joint Commission standards Prepares and maintains patient log in accordance with established policies and procedures Assist in the production of medical record policies and makes recommendations for revisions as needed Works with medical and professional staff to identify and solve problems, implement process improvements, and ensure timeliness of data collection Orients physicians to utilization of transcription equipment and resolves problems with equipment as need arises Coordinates the exchange of records with an offsite storage facility Performs other duties as assigned Education High School diploma or GED required. Associates Degree in Health Information Management preferred. Licenses/Certifications Currently credentialed as a Registered Health Information Technician (RHIT) by the American Health Information Management Association (AHIMA) preferred. Experience Must have a minimum of two years' experience in medical records. Experience in a hospital setting preferred. Must possess working knowledge of Joint Commission standards. Physical Requirements for Essential Job Functions Ability to lift 50 lbs. occasionally, 20 lbs. frequently and 10 lbs. constantly Ability to walk and stand 80% of an 8 to 12 hour shift Must possess sight/hearing senses or use prosthetics that will enable senses to function adequately so that requirements of the position can be fully met Noland Hospital Birmingham - Downtown

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