Health Information Professional

AltaPointe Health Systems; Mobile (AL); On-site; USD 37,000 - 46,000; Full time

Job summary

AltaPointe Health Systems is seeking a Health Information Clerk to process requests for health records after discharge, review medical records for accuracy, and assemble records for imaging. You will work to maintain confidentiality, manage chart tracking, and support clinicians in locating charts across departments.

The role emphasizes attention to detail, adherence to CMS/DMH/Joint Commission standards, and efficient filing and release of information. Strong organizational skills are essential.

Qualifications

• High school graduate or the equivalent.
• Two to three years’ experience in a medical records department or health care office setting.
• Knowledge of medical and psychiatric terminology.
• Ability to communicate verbally, withstand continual deadlines, concentrate and maintain accuracy under interruption.
• Detail oriented and highly organized.
• Knowledge of CMS, DMH and The Joint Commission requirements.
• Basic clerical skills including Microsoft Office.
• Use of standard office equipment and general EHR/medical records procedures and standards.

Responsibilities

• Receives and processes all requests for health records from file area after consumers’ discharges.
• Reviews and analyzes medical records for accuracy, completion, and timeliness of documentation.
• Assembles record in chronological order during review, and prepares record for imaging.
• Checks and documents chart deficiencies for staff (Inpatient) and completes Administrative Reviews (Outpatient).
• Correctly categorizes deficiencies based on color coding system in use.
• Obtains missing information and corrects deficiencies within standard compliance timeframes.
• Protects and maintains confidentiality of all records and patient information.
• Maintains the chart tracking system to locate each record.
• Assists clinicians with pulling and locating charts.
• Sorts incoming charts and routes to proper location and clinician.
• Ensures charts are filed back promptly by end of each workday.
• Completes and processes authorizations to release information as requested.
• Answers the telephone professionally per 5 Star Customer Service standards.
• Orders, maintains, and distributes AltaPointe approved forms.
• Assists in purging records for destruction on a regular basis.
• Adheres to program procedures and protocols as outlined by the Assistant Coordinator of Health Information.

Education

High school diploma or equivalent

Job description

• Receives and processes all requests for health records from file area after consumers’ discharges.


• Reviews and analyzes medical records for accuracy, completion, and timeliness of documentation.


• Assembles record in chronological order during review, and prepares record for imaging.


• Checks and documents all chart deficiencies for nurses, doctors, therapists and behavioral staff (Inpatient), and completes Administrative Reviews (Outpatient).


• Correctly categorizes deficiencies based on color coding system in use.


• Obtains all missing information and corrects all deficiencies in records within standard compliance timeframes.


• Protects and maintains the confidentiality of all records and patient information.


• Maintains the chart tracking (charge-out) system to track the location of each record.


• Assists clinicians with pulling and locating charts.


• Sorts incoming charts and ensures they are routed to the proper location and clinician.


• Ensures charts are filed back promptly by the end of each workday.


• Completes and processes authorizations to release of information as requested.


• Answers the telephone in a professional manner using 5 Star Customer Service standards.


• Orders, maintains, and distributes AltaPointe approved forms.


• Assists in purging records for destruction on a regular basis.


• Adheres to program specific procedures and protocols as outlined by the Assistant Coordinator of Health Information.

Primary Job Functions

• Receives and processes all requests for health records from file area after consumers’ discharges.


• Reviews and analyzes medical records for accuracy, completion, and timeliness of documentation.


• Assembles record in chronological order during review, and prepares record for imaging.


• Checks and documents all chart deficiencies for nurses, doctors, therapists and behavioral staff (Inpatient), and completes Administrative Reviews (Outpatient).


• Correctly categorizes deficiencies based on color coding system in use.


• Obtains all missing information and corrects all deficiencies in records within standard compliance timeframes.


• Protects and maintains the confidentiality of all records and patient information.


• Maintains the chart tracking (charge-out) system to track the location of each record.


• Assists clinicians with pulling and locating charts.


• Sorts incoming charts and ensures they are routed to the proper location and clinician.


• Ensures charts are filed back promptly by the end of each workday.


• Completes and processes authorizations to release of information as requested.


• Answers the telephone in a professional manner using 5 Star Customer Service standards.


• Orders, maintains, and distributes AltaPointe approved forms.


• Assists in purging records for destruction on a regular basis.


• Adheres to program specific procedures and protocols as outlined by the Assistant Coordinator of Health Information.

Supervision and consultation

• Seeks supervision and consultation as needed


• Accepts and employs suggestions for improvement


• Actively works to enhance skills.

Courteous and respectful towards consumers, visitors and co-workers.

• Treats consumers with care, dignity and compassion.


• Respects consumers’ privacy and confidentiality.


• Works in a cooperative manner with other AltaPointe employees.


• Assists consumers and visitors as needed.


• Personal values don’t inhibit ability to relate and care for others.


• Is sensitive to the consumers’ needs, expectations and individual differences.


• Is gentle and calm with consumers, families, and others as appropriate.

Administrative

• Actively participates in Performance Improvement activities.


• Actively participates in AltaPointe committees as required.


• Completes assigned tasks in a timely manner.


• Follows AltaPointe policies and procedures.


• Attends appropriate in-service training and other workshops.


• Other duties as assigned.

Physical Requirements of the Job

• Continuous sitting (extended sitting) up to 2 hours at a time until break or lunch.


• Reaching forward to place paperwork on a document stand.


• Grasping to turn keys in doors throughout facility, grabbing files/paperwork.


• Lifting up to 10 pounds.


• Carrying up to 10 pounds to transport small quantities of charts various distances in facility.


• Fine manipulation/dexterity for data entry, writing and handling paperwork


• Standing and walking frequently throughout shift and to various locations in the facility to file charts and put up supplies.


• Sitting can be in frequent bursts up to 10 minutes.


• While filing in the medical records department, the employee may bend forward, squat, lunge, stoop or crouch to access the levels that are at floor to waist level.


• Forward reaching, reaching out to front, and overhead reaching with up to 5 to 15 pounds is performed when filing records and charts.

High school graduate or the equivalent; two to three years’ experience in a medical records department or health care office setting; knowledge of medical and psychiatric terminology; ability to communicate verbally, withstand continual deadlines, concentrate and maintain accuracy in spite of frequent interruptions; detailed oriented and highly organized; knowledge of the following must be demonstrated within 6 months of hire

• Understanding of documentation requirements and procedures in compliance with key agencies that include, but are not limited to, CMS, DMH and The Joint Commission


• Basic clerical skills including Microsoft Office, and the principles of alphabetic, numeric, and terminal digit filing


• Use of standard office equipment including copy machines and fax machines, and


• General EHR and medical records procedures and standards.