Medical Records Specialist

Talentify; Downey (CA); On-site; USD 30,000 - 44,000; Full time

Job summary

US Tech Solutions is seeking a Health Information Management professional in Downey, CA, onsite, M-F 8am-4:30pm. The role coordinates physician medical record completion and performs quantitative analysis per Title 22, CIHQ, and Medical Staff regulations.

Responsibilities include safeguarding patient information, ensuring safety, notifying physicians for record completion, and analyzing incomplete records with chart tracking updates. Requires 3–5 years of MR experience and EHR proficiency.

Qualifications

• 3-5 years of Medical Record experience in an acute care setting.
• Experience with electronic health record applications.

Responsibilities

• Safeguards and preserves the confidentiality of patient’s protected health information in accordance with HIPAA and policies.
• Ensures a safe patient environment and adherence to safety practices per policy.
• Resolves patient/guardian biophysical, psychological, educational, and environmental needs when administering care.
• Notifies physicians of records requiring completion and maintains documentation of notifications.
• Administers medical staff guidelines for record completion and monitors pending/unsigned orders.
• Retrieves incomplete records and assists physicians in completing records electronically.
• Activates temporary suspension of medical staff privileges when records are not completed timely and documents suspensions.
• Analyzes incomplete records; updates chart tracking to current status.
• Scans loose filings into ChartMaxx; uses ChartMaxx for deficiency analysis and reporting.
• Adheres to daily productivity standards and oversees incomplete medical record activities.
• Assists physicians with record completion issues and escalates unresolved cases.
• Completes RLDatix Incident Reports for potential events identified during review.

Skills

Medical terminology

Keyboarding 35 wpm

Detailed oriented

Pressure deadline management

Office equipment proficiency

Title 22 CIHQ knowledge

Education

High School Diploma/GED

Tools

ChartMaxx

RLDatix

eScription1 monitoring

Job description

Job Description:

• Shift/Schedule: Onsite, M-F 8am-4:30pm.
• This position processes health information under the direction of the HIM Director or designated supervisor. This position is responsible for coordinating physician medical record completion and the quantitative analysis of all medical record patient types based upon standards established by Title 22, CIHQ, Conditions of Participation and the Medical Staff Rules and Regulations.

Responsibilities:

• Safeguards and preserves the confidentiality of patient’s protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital, and departmental policies.
• Ensures a safe patient environment and adherence to safety practices per policy.
• With consideration to age, employee utilizes the approved process to resolve biophysical, psychological, educational, and environmental needs of patient/significant other when administering care.
• Notifies physicians of medical records requiring their completion in accordance with Medical Staff Bylaws, Rules and Regulations, Title 22, and Center for Improvement in Healthcare Quality (CIHQ) and all other applicable regulatory agencies. Maintains documentation of the notifications.
• Administers all medical staff guidelines as it pertains to the medical record completion, uniformly and consistently among all members of the medical staff. May perform daily counts of number of records pending completion using the computer-generated reports. Monitors unsigned and refused electronic orders, tasks, and documents.
• Retrieves incomplete records and/or assists physicians on a one-to-one basis in completing their records electronically.
• Activates temporary suspension of medical staff privileges when records are not completed in a timely manner. Communicates suspension information to other departments per Health Information Management Department procedures. Maintains documentation of days on suspension to fulfill mandated reporting requirements and Medical Staff reappointment/credentialing needs.
• Analyzes and re-analyzes incomplete paper and electronic medical records to assure the completeness of information. Updates chart tracking system to reflect the current status of the incomplete record.
• Scans loose filing into the ChartMaxx System.
• Utilizes ChartMaxx to accomplish deficiency analysis and reporting.
• Adheres to daily productivity standards provided in separate documentation.
• Oversees all incomplete medical record activities and functions.
• Assists physicians with record completion issues and escalates them if resolution cannot be achieved in a timely manner.
• Completes a RLDatix Incident Report for any potential compensable event identified during the record review or completion process.
• Conducts record review function with established criteria and provides data to Director or designated supervisor.
• Able to perform basic eScription1 monitoring, pending and look up functions
• Operates the office equipment normally used in the routines of daily work, such as photocopy machine, facsimile (FAX) equipment, computers, scanners, and telephones.
• Must be able to communicate effectively with all ages of customers served.
• Abides by and strongly enforces all compliance requirements and policies and performs his/her responsibilities in an ethical manner consistent with the organization’s values.

Experience:

• 3-5 years of Medical Record experience in an acute care setting
• Previous experience with electronic health record applications

Skills:

• Medical Record documents. Able to categorize forms/documents within the medical record. Physician chart completion and chart deficiency analysis
• Basic keyboarding skills. Typing speed of 35 wpm
• Must be knowledgeable of medical terminology and familiarity with computers. Must be detailed oriented, self-motivated
• Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements
• Ability to use standard office equipment including computers, photocopy, facsimile (FAX) and scanners
• Knowledge of Title 22, CIHQ, Conditions of Participation, Medical Staff Bylaws and Medical Staff Rules and Regulations.

Education:

• High School Diploma/GED

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.