Health Information Professional (Daphne, EastPointe Hospital)

AltaPointe Health Systems; Daphne (AL); On-site; USD 30,000 - 42,000; Full time

Job summary

AltaPointe Health Systems in Daphne, AL is seeking a Medical Records Clerk to process health-record requests after patient discharges and review records for accuracy and completeness.

The role includes assembling charts, documenting deficiencies, preserving confidentiality, and supporting clinicians with locating records. Strong MS Office and basic EHR skills are beneficial for success.

Qualifications

• High school diploma or equivalent required.
• 2–3 years in medical records or health care office preferred.
• Knowledge of medical and psychiatric terminology preferred.
• Within 6 months of hire, demonstrate understanding of CMS, DMH and The Joint Commission documentation requirements.
• Basic clerical skills including MS Office; familiarity with EHR systems.

Responsibilities

• Receive and process all health-record requests after discharges.
• Review medical records for accuracy, completeness and timeliness.
• Assemble records in chronological order and prepare for imaging.
• Document deficiencies and complete administrative reviews.
• Protect confidentiality of patient information.
• Maintain chart tracking and assist clinicians in locating charts.
• Route charts to proper locations; ensure end-of-day filing.

Skills

Medical records

Data entry

Terminology knowledge

Customer service

Education

High school diploma or equivalent

Tools

Microsoft Office

Job description

EastPointe Hospital is a private, free-standing psychiatric hospital for adults and adolescent males (ages 12 - 18) located in Daphne, Ala.
EastPointe’s clinical and medical professionals assess and evaluate adults and adolescents in psychiatric crisis.
Treatment focuses on stabilizing psychiatric symptoms and preventing psychiatric commitment.
Adults and/or adolescents admitted to EastPointe will have exhibited life‑threatening, destructive or disabling behavior or symptoms.
Each patient completes a psychiatric diagnostic evaluation and receives 24‑hour clinical care for the duration of their stay.
The goal is for each patient to return to home or to the least restrictive level of care.

Essential 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

• 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 is required.
Two to three years’ experience in a medical records department or health care office setting preferred.
Knowledge of medical and psychiatric terminology preferred.
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.