Job Description

Medical Record Specialist

Under direct supervision, maintains a comprehensive medical record consistent with all federal, state and company policies and procedures, and performs general secretarial duties to support their assigned interdisciplinary team(s).

Education: HS Diploma, GED or equivalent Experience: Experience in health care field is preferred 1 year's customer service or administrative experience; additional education beyond high school may be substituted for experience Skills:

• Knowledge of medical terminology is preferred
• General knowledge of office practices, procedures, and equipment; of business English, spelling, punctuation, grammar and basic arithmetic calculations
• Skill in using a variety of office software applications, such as word processing, spreadsheets, presentation packages, and database applications to produce documents
• Skill in understanding and following oral and written instructions and in communicating effectively both orally and in writing
• Skill in accurate alphabetical and numeric filing
• Able to multi-task and prioritize in a busy environment
• Strong time management skills

Patient & Workplace Safety:

• Employee has knowledge and understanding of patient and workforce safety as it relates to job duties.

Patient Population:

• Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.

Principal Duties and Responsibilities:

• Generates and electronically files appropriate patient related information for the medical record consistent with company policy and regulatory requirements.
• Prepares mailings to physicians and assures that all MD orders are received, signed and returned within 30 days receipt of the order. Works with staff to hand deliver these forms to physicians when necessary to meet established timelines.
• Regularly runs Missing Plans of Care and Orders reports and works to obtain missing information.
• Requests medical records from doctors' offices, hospitals, facilities and/or family members. Requested records may include, but are not limited to, history and physical, labs, tests, imaging, and other clinical documentation.
• Prints patient care plans, medication order sheets and demographic information from the electronic medical record for patients being transferred to other facilities for treatment, (e.g. transfers to out of area facilities, patients being transferred upon request, or per policies and procedures) Responds to requests for records to facilitate treatment delivery by other related providers.
• Supports and attends weekly interdisciplinary team meetings and updates EMR with interdisciplinary team documentations.
• Prepares all documentation for all IDT members. Collects all documentation from clinical staff during IDT meeting and enters into the EMR.
• Prepares all necessary paperwork for re-certifying patients for on-going care by the MD and Clinical Manager per regulatory guidelines. (Current guidelines require that forms be signed within 15 days of the patient's re-certification date or 2 days after said date).
• Reviews documentation to ensure quality and accuracy.
• Maintains IDT meeting attendance records in Homeworks.
• Prepares agenda for IDT to ensure all patients are discussed within regulatory guidelines.
• Conducts regulatory audits of patient charts while on service.
• Reviews inactive patient medical records and closes the record within 30 days of the patient's discharge date.
• Responsible for communicating with pharmacies and mailing/faxing prescriptions written during IDT to appropriate pharmacies.
• Responds to record requests from outside sources and the billing department by coordinating and preparing the chart for release to the appropriate individuals for final review and mailing.
• Identifies patient needs and regulatory requirements associated with their medical insurance.
• Prints MTM assessment forms for review daily by the Clinical Managers.
• Obtains Medical Director signature on MTM assessment forms and scans into EMR weekly.
• Provides administrative support services preparing daily reports for the Clinical Manager.
• Gathers data and information as directed. May use data to develop administrative and statistical reports.
• Responds to phone calls, e-mails, and mailings timely.
• Provides coverage for other teams as needed; assists other HIM Specialists as time permits.
• Prepares patient charts for review by Department of Appeals through Medicare after patient discharge.
• Discharges patients in the EMR who have either discharged, revoked, or been transferred to another facility.
• May process and respond to requests for radiology images following the HIPAA Guidelines and privacy regulations.

All roles must demonstrate GBMC Values

Respect

• Treats others with fairness, kindness, and respect for personal dignity and privacy
• Listens and responds appropriately to others' needs, feelings, and capabilities

Excellence

• Meets and/or exceeds customer expectations
• Actively pursues learning and self-development
• Pays attention to detail; follows through

Accountability

• Sets a positive, professional example for others
• Takes ownership of problems and does what is needed to solve them
• Appropriately plans and utilizes required resources for various job duties
• Reports to work regularly and on time

Teamwork

• Works cooperatively and collaboratively with others for the success of the team
• Addresses and resolves conflict in a positive way
• Seeks out the ideas of others to reach the best solutions
• Acknowledges and celebrates the contribution of others

Ethical Behavior

• Demonstrates honesty, integrity and good judgment
• Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

• Embraces change and improvement in the work environment
• Continuously seeks to improve the quality of products/services
• Displays flexibility in dealing with new situations or obstacles
• Achieves results on time by focusing on priorities and manages time efficiently

Pay Range

$17.35 - $26.36

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

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