Medical Records Technician, Medical Records

at  RWJBarnabas Health

JOB OVERVIEW:

Cross-trained in all areas of the Health Information Management Department: chart quality control, transcription, queries, Analysis/chart deficiencies, prepping, scanning, boxing, birth certificates, death certificate validation, chart correction, audits, suspension process, processing commitment papers and working Epic Queues. Maintains chart quality in both the paper and electronic record. Ensures all operative reports and H&Ps are dictated/available within 24 hours of any surgical procedure. Follows up with physicians regarding query completion. Reconciles deficiency report and updates aging and suspension lists accordingly. Assists and educates all new physicians with regard to medical record completion. Assists HIM Data Analyst with job function. Able to assist with clerical tasks as needed, including, but not limited to: chart assembly, scanning and storage.

QUALIFICATIONS:

Required:

• High School graduate or equivalent
• Successful Completion of all Orientation Programs
• Exceptional communication skills
• Great attention to detail
• Collaborative attitude

Preferred:

• Minimum of three years clerical experience

SCHEDULING REQUIREMENTS:

• Sunday - Thursday or Tuesday - Saturday, 8am - 4pm (weekday) and 6am - 2pm (weekend and when assigned for weekday chart pickup).
• Full Time

• Provides a compassionate and supportive environment with prompt and consistent service
• Adheres to patient rights: provides for the confidential treatment of all communications and records
• Demonstrates professionalism with families, visitors, physicians, co-workers and supervisors
• Listens and communicates effectively
• Supports teamwork by cooperative problem solving through participation in meetings, projects, etc.
• Utilizes principles of PDSA in all work situations to assess, measure and improve organizational and department functions
• Organizes work sets priorities with a minimum of supervision and seeks guidance as appropriate
• Makes decisions that are timely and consistent with department, objectives, policies and procedures
• Demonstrates sound judgment; accepts and benefits from constructive criticism
• Participates in ongoing education as required
• Ensures receipt of all inpatient/outpatient records with follow up for all missing records
• Assembles/preps and analyzes medical records per Hospital guidelines for chart order. Records to be assembled by oldest discharge date first
• Charts are to be scanned/indexed in order, i.e. page one before page 2 etc. Cover batch sheet to be generated and printed and placed on charts
• Works with providers to resolve and questions or concerns surrounding chart completion/documentation
• Verifying and correcting date of death
• Audits/release to Inspector and review and approve
• Ensures admission assessments are completed within 24 hours and notifies provider
• Daily creation and distribution of suspension lists/notices including daily OR Booking hold
• Accurately prepares records for pick-up
• Monitors and ensures MMF, On-Base and Epic Work Queues are up to date
• Ensures time corrections and done timely upon receipt
• Process commitment papers upon receipt
• Ensures all documents are scanned timely upon receipt
• Meets and sustains productivity standards
• Refer all unresolved issues to Operations Manager
• Verifies patient name, medical record number and patient account numbers on all sheets to ensure correct reports are in correct patient chart and on correct admission
• Performs other duties as required